When a practice makes the switch from paper records to EMR, some legal concerns will arise. Decisions must be made to be sure the digital records maintain legal integrity. There may also be some surprises regarding issues of privacy, security, and compliance. Here are some things to keep in mind:
Documentation: When you write an exam onto a piece of paper and add your signature, you create a legal document. You probably are aware of the necessity for documentation and the problems which can occur when alterations are made to medical records. Paper charts’ integrity are normally easy to determine. An electronic chart may be more complicated. The Healthcare Information and Management Systems Society says that electronic records need to be stored in a legal manner; otherwise the records can be considered hearsay and legally challenged.
What makes this so important? If your electronic records do not satisfy the requirements for a legal medical record, a payor can sometimes deny claims. Even worse, you could expose your practice to increased risks of adverse litigation outcomes. Not only do you have to make sure your electronic records aren’t altered – you must also be able to demonstrate your procedure.
So how can you be sure your electronic medical records aren’t able to be changed? Ideally your system will allow users to make changes and correct errors while keeping the integrity of the record intact.
* Does your system have a strict security protocol which isn’t too time-intensive? Alphanumeric passwords that must be changed periodically? Automatic time-out for inactivity?
* Does it restrict access to certain features? You wouldn’t want a front desk employee changing patients’ intraocular pressures.
* Does it timestamp each entry and show an audit trail? This could be achieved by writing an unalterable record of every entry and event to prove the record’s validity.
* Does it use a secure lock-out feature? One might allow a doctor to make changes at day’s end, but after twenty-four hours a record would lock. This may seem a harsh measure, but it may serve you well by protecting you from unauthorized changes.
* Does the system keep track of who documented what? You don’t want your name associated with another user’s entries, or anonymous changes made.
If you keep these considerations in mind you’ll be able to maintain a proper archive without compromising the records’ legal authenticity.