1. © 2009 Cengage Learning. All Rights Reserved. Electronic Health Records

2. © 2009 Cengage Learning. All Rights Reserved. Agenda  Paper vs. electronic records  Legal issues  Email and PHI  Records retention and destruction

3. © 2009 Cengage Learning. All Rights Reserved. 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

4. © 2009 Cengage Learning. All Rights Reserved. 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

5. © 2009 Cengage Learning. All Rights Reserved. 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

6. © 2009 Cengage Learning. All Rights Reserved. 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

7. © 2009 Cengage Learning. All Rights Reserved. Accreditation Issues  Voluntary accreditation (e.g., Joint Commission, NCQA)  CMS requirements Electronic prescriptions

8. © 2009 Cengage Learning. All Rights Reserved. Legal Issues in EHR  Authentication Provider documentation  Admissibility State law and rules of evidence  Hearsay  Best evidence rule

9. © 2009 Cengage Learning. All Rights Reserved. Email and PHI  HIPAA Privacy and Security Rules for EPHI  Electronic Privacy Communication Act  Common problems associated with Internet

10. © 2009 Cengage Learning. All Rights Reserved. Records Retention and Destruction  State law requirements for retention of different types of records  CMS requirements for patient records  Business practices