Medical records - Summary of the Physicians Health Information System
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1 Medical Records: Policy Updates Mark Staz (Policy Analyst CPSO) QUALITY PROFESSIONALS HEALTHY SYSTEM PUBLIC TRUST
2 Question:
3 Results:
4 Theme: Nothing has changed and yet everything is different (Jean-Paul Sartre)
5 Theme: Nothing has changed and yet everything is different (Jean-Paul Sartre)
6 Overview: Policy Review (what we ve seen & done) Policy Updates (especially the ones that matter to assessors) Electronic Records Section Procedural Medicine Additional Issues Identified
7 Policy Review May 12 Nov 11 Feb 12 Jan 11 Feb Apr 11 Preliminary consultation Draft for consultation Final draft Dec 10 Working group formed Research
8 Goals Electronic Records (more guidance!) Record keeping in Procedural Medicine Policy Length
9 Electronic Records:
10 Stages of EMR Adoption Paper Initial choices Transition period Full EMR user
11 Initial Choices Choosing a Product/Vendor should research available products in order to choose an EMR that meets their needs Consult OntarioMD (vendor assessment tool) Appendix G : Choosing an EMR Vendor
12 Transition period: If you want to destroy paper records, Written procedures for scanning are developed and consistently followed, Appropriate safeguards are used to ensure reliability of digital copies, A QA process is established, followed, and documented E.g. compare scanned copies to originals to ensure accuracy Save scanned copies in read only format
13 Transition period: Optical Character Recognition (OCR) Follow same QA procedures for all records strongly recommended that physicians either retain the original record or a scanned copy
14 Full EMR User: Storage: Routine back up (requirement) Reminder: risk of loss increases when multiple patients records are stored on a portable electronic device
15 Full EMR User: Security: Encryption All personal health information contained on an EMR or a mobile device must be strongly encrypted Where possible, physicians should use a secure e mail system with strong encryption
16 Full EMR User: Networking Assess risks involved Ensure your network is sufficiently secure Only exchange the minimum amount of PHI necessary to provide care (i.e. limit exposure and potential for privacy breach)
17 Key Messages: have ultimate responsibility for meeting all legal and regulatory requirements with respect to electronic records
18 Key Messages: Good record keeping practices are essential for e records as much as for paper records
19 Key Messages: Same records, new look same rules
20 Goals Electronic Records (more guidance!) Record keeping in Procedural Medicine Policy Length
21 Goals Electronic Records (more guidance!) Record keeping in Procedural Medicine Policy Length
22 Procedural Medicine: Consultants Records Operative Notes Diagnostic/Interventional Procedural Notes Consultation Reports (including follow up) Discharge Summaries
23 Sources: Public Hospitals Act Records Regulation, Medicine Act, 1991 Guide to Better Physician Documentation RCPSC & CFPC Guide to Enhancing Referrals and Consultations Between CPSO Practice Guide
24 Goals Electronic Records (more guidance!) Record keeping in Procedural Medicine Policy Length
25 Goals Electronic Records (more guidance!) Record keeping in Procedural Medicine Policy Length
26 Goals Electronic Records (more guidance!) Record keeping in Procedural Medicine Policy Length
27 Goals Electronic Records (more guidance!) Record keeping in Procedural Medicine Policy Length BUT
28 We Trimmed the Fat!
29 Additional goals Address problems we ve seen: General Assessments (not performed; insufficient detail) CPPs (not used; not up to date) Flow Sheets for Chronic Diseases (not used) Templates (pre populated and often not reflective of actual encounter)
30 Updates: Cumulative Patient Profile (CPP): Family Practice: MUST MAINTAIN Specialist: Strongly Recommended
31 Chronic Disease Flow Sheets: More Resources!
32 Asthma
33 COPD
34 Preventive Care College of and Surgeons of Ontario
35 Diabetes College of and Surgeons of Ontario
36 Templates: must avoid overreliance on pre populated templates Consider an EMR that allows customization of templates or entry of free text Message: Capture detail and nuance!
37 Updates:
38 Updates: Short Forms/abbrev. Principle: Meaning should be clear to other HCPs reading the record N.B. Patient may access record (i.e., reconsider using S.O.B. )
39 Updates: Language Requirement: or
40 Updates: Chronological & Systematic File by Date File by Patient
41 Collection, Use, and Disclosure of PHI Circle of Care : can assume a patient s implied consent under circumstances defined in PHIPA This is one form of authorization physicians should exercise care and caution when disclosing personal health information to anyone outside the circle of care
42 Commercial Service Providers Agreements made with external service providers must reflect the same legal and regulatory requirements that apply to physicians as health information custodians Exercise due diligence Seek legal advice (CMPA) Make agreements in writing!
43 Accountability: Audit Trails must be aware of all others who can access their records or their EMR system and what functions they are able to perform User I.D. and Password Restricted Access (role based) Confidentiality Agreements
44 Accountability: Audit Trails For electronic systems, there must be a functioning audit trail or record of who has accessed an EMR and what additions or edits they have made to the record over time.
45 Shared Records Multispecialty/Interprofessional setting Multidisciplinary Hospital/Clinic EHR environment
46 Security: Shared Records are responsible for their entries into the EMR not for entries or changes of others to the EHR
47 Thank you!
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