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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