Electronic Health Records

Agenda

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

Paper vs. Electronic Records

Legal health record 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.

Electronic health record (EHR) 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

HIPAA Enables electronic health records Preempts any state law that conflicts

E-SIGN Puts electronic signatures and records on

par with paper Preempts any state law that conflicts

State Licensure for Any Health Records

Defines required contents of patient charts

May also have requirements for EHR as long as they don’t conflict with HIPAA and E-SIGN

Accreditation Issues

Voluntary accreditation (e.g., Joint Commission, NCQA)

CMS requirements Electronic prescriptions

Legal Issues in EHR

Authentication Provider documentation

Admissibility State law and rules of evidence

Hearsay Best evidence rule

Email and PHI

HIPAA Privacy and Security Rules for EPHI

Electronic Privacy Communication Act Common problems associated with

Internet

Records Retention and Destruction

State law requirements for retention of different types of records

CMS requirements for patient records Business practices