When medical practices change over from paper to electronic medical records (EMR), steps must be taken to ensure that the records remain legally sound. The change to electronic medical records brings up some issues with compliance, privacy, and security. Below you will find some important considerations to make when switching your practice over to EMR.
When writing an exam on a piece of paper and signing it, you create a legal document. You are most likely familiar with the problems that can result from changes to medical records, and the importance of good documentation. The Healthcare Information and Management Systems Society (HIMSS) asserts that electronic medical records must be stored legally. Otherwise, these records can be challenged as hearsay and deemed invalid.
This is important, because when electronic medical records do not meet the legal requirements, a payor can sometimes deny a claim. Also, you could create the risk of an adverse outcome in litigation. In addition to being sure your electronic records aren’t altered, you must also be able to demonstrate the procedures which are used to ensure this.
How, then, can you make sure your electronic records can’t be altered? The ideal system lets users make updates and correct errors while keeping the record’s legal integrity intact. Ask yourself the following questions:
* Does the system keep a record of who is accessing and writing to the record? You wouldn’t want your name appearing as the author of another user’s entry.
* Does it contain a security protocol which is strict but not too time-consuming? Features could include an automatic time-out after a period of inactivity, and periodic changes to the alphanumeric passwords.
* Does the system prevent access to certain critical features? For example, an employee working the front desk shouldn’t be able to edit a patient’s clinical findings.
* Does it use a secure ‘lock-out’ feature? Perhaps you want the doctors to be able to make changes at the end of the day, but after a certain amount of time has passed the record should lock. This sort of feature helps protect you by preventing unauthorized changes.
* Does the system write time stamps on all entries, to show an audit trail? For example, the system could write an unalterable draft of each event and entry.
By paying attention to these important considerations, you’ll be on your way to ensuring your electronic medical records system is legal and defensible.