I recently discussed some issues related to electronic medical records, including what constitutes a legal record, ways to maintain record integrity with devices such as an audit trail, and preventing tampering with these records. Now let’s take a look at some other terms to familiarize yourself with.

Patient Privacy:

Do you remember when HIPAA first hit the scene? You can no longer keep a patient registration form at the front desk, or risk a patient knowing who else was there that day. The penalty could include jail time.

Improper charge:

Some recent legal cases have established that accessible data must be producible, including supporting data. While this may seem like an unfair burden on a medical practice, experts who deal with these types of legal cases believe that EMR will result in a decrease in malpractice lawsuits, as a result of better documentation and a lower fee. of medication-related errors. Still, if data is stored on a failed hard drive and data recovery costs are significant, it could create an undue burden; the judges could rule that the expense be shared between the two parties.

Accessibility:

In the world of paper records, charts that are older than seven years and have been purged are considered legally ‘inaccessible’. If a plaintiff’s attorney asks you to produce the record, it’s impossible. However, when it comes to electronic information, inaccessibility might be more difficult to prove, since electronic data can almost always be recovered. In fact, most current EMR software systems don’t even allow a provider to delete patient records.

electronic discovery:

Discovery is the pre-trial phase in a lawsuit. Each party can compel the production of evidence by means of a subpoena or a declaration. E-Discovery refers to information stored in an electronic format. The collection of digital evidence has even spawned the field of cyber forensics. This column cannot adequately cover a topic as broad as E-Discovery. This has become an important area of ​​the law and will become increasingly important as EMR becomes the norm. The bottom line for medical practices is that a reliable and secure backup process is a must.

Eventually, rational minds emerged victorious, and some of the sillier regulations have been relaxed a bit. Privacy concerns that are specific to the electronic aspects of medicine still exist, relating to inappropriate disclosure of patient data. Unauthorized email, an unsecured wireless network, a computer monitor turned on in view of another patient, and the unauthorized distribution of reports are some of the main examples.

Consider forming a Legal, Risk and Compliance Committee (LRC) for your practice, to address the issues listed above and others that may arise. Continually ask yourself what mishaps could happen, including when, how, and by whom. So when you face a legal challenge, you’ll be better prepared.