Physician Responsibilities in the Transition to Electronic Medical Records
Posted Oct 30 2008 3:21pm
The College of Physicians and Surgeons of British Columbia has published an article in the December 2007 edition of the College Quarterly titled: "Considerations During the Transition to Electronic Medical Records" A short excerpt is provided.
The implementation of an EMR will necessitate process changes in your practice. Processes designed on the movement of paper charts should be assessed and altered accordingly.
Protection of personal health information is of paramount importance. Assess the security risks in your office. Security policies and staff education should take place to address specific concerns.
Physicians may choose either to scan paper records electronically in a “read only” format, e.g. pdf, or to start entering data from day one of their new EMR. Either way, the College recommends that paper records be kept in close proximity for at least six months. Unless they are completely scanned into the EMR, paper records must be kept indefinitely if the patient continues to attend. If the patient has left or moved, paper records must be kept for at least seven years from the date of last patient contact (or until the patient reaches age 26 for patients under 19).
Physicians must ensure that complete medical records (paper, electronic or a combination of both) are accessible at all clinical decision points and for the duration of the retention period prescribed under Rule 13 of the Medical Practitioners Act.
EMRs must be able to be printed promptly if required.
Each practice must identify in writing the level of access by any authorized persons utilizing EMRs.
If your EMR is located on a server in your office, ensure that the server is physically secure and robust backup procedures are in place.
Numerous commercial EMR products are available. A suitable EMR program must have the following attributes:
Audit trail for information entry;
Capability of physicians to provide sign off on documentation, orders and prescriptions using electronic signatures or equivalent authentication;