Electronic Health Records Agenda o Paper vs electronic

Electronic Health Records

Agenda o Paper vs. electronic records o Legal issues o Email and PHI o Records retention and destruction

Paper vs. Electronic Records o Legal health record n n n Contents of a paper medical chart along with radiology films and other imaging Must meet federal and state law standards Must meet CMS and healthcare accrediting agency requirements

Paper vs. Electronic Records contd. o Electronic health record (EHR) n n n Computerized format of a patient’s paper health records Part of health information technology system Consists of integrated information systems and technologies, with different data and images

Federal Laws and Preemption o HIPAA n n Enables electronic health records Preempts any state law that conflicts o E-SIGN n n Puts electronic signatures and records on par with paper Preempts any state law that conflicts

State Licensure for Any Health Records o Defines required contents of patient charts o May also have requirements for EHR as long as they don’t conflict with HIPAA and E-SIGN

Accreditation Issues o Voluntary accreditation (e. g. , Joint Commission, NCQA) o CMS requirements n Electronic prescriptions

Legal Issues in EHR o Authentication n Provider documentation o Admissibility n State law and rules of evidence p Hearsay p Best evidence rule

Email and PHI o HIPAA Privacy and Security Rules for EPHI o Electronic Privacy Communication Act o Common problems associated with Internet

Records Retention and Destruction o State law requirements for retention of different types of records o CMS requirements for patient records o Business practices