 Transitioning to electronic medical records
If you have been observing the move to electronic medical records (EMRs) from the sidelines, take heart: you are not alone. In the CMPA’s 2009 survey of Canadian physicians, only 43 per cent of respondents say they currently use some form of electronic record in their practice. However, the CMPA survey suggests that the number of Canadian doctors using an EMR is expected to rise rapidly, as is the case in other countries. The survey also suggests that nearly a third of physicians believe the use of electronic records will increase the risk of medical liability. The CMPA has responded to its members’ concerns by offering advice for physicians who use or are considering the use of electronic records for managing their patients’ information. In 2009 the Association published the Electronic Records Handbook, which is a practical resource that focuses on how to address implementation issues and mitigate medico-legal risk. What is an EMR?
An EMR is an electronic version of the paper record generally maintained by doctors about their patients. It may be a relatively straightforward office-based system or a more complex shared record that connects health care professionals through a network. The record itself may contain a variety of information about the patient and his or her medical history, including consultation reports and laboratory results. The big switch— What to migrate When implementing an EMR system, physicians will need to decide what to do with existing paper records. Similar issues arise when switching from old “legacy” EMR software to new software. In either case, you must determine what patient information you need to migrate or archive. The decision on what patient information should be migrated into the new EMR may depend on your practice. At a minimum, you will likely wish to migrate the patient’s demographic or core data information (including name, birthdate, contact information, and health card number). Many physicians may also see the value in migrating the “patient profile,” which might typically include a summary of personal and family data, past medical history, risk factors, allergies and drug reactions, ongoing conditions, and current medications. It is also possible that the appropriate system for your practice may be to use the new electronic records system, together with a residual paper system and/or scanned copies of the paper records. During any major transition, some disruption to normal work processes is inevitable. To help minimize disruption, the transition to a new EMR system is often a gradual one, particularly if laboratory reports and other correspondence continue to be received in paper form. Most regulatory authorities (Colleges) encourage physicians to ensure that processes are in place to facilitate continuity of care during the transition. Documents received via paper or through the legacy system must be dealt with appropriately. It may also be helpful to clearly identify a record as the primary record, parallel record, or partial record. During the transition period when working with two systems, some Colleges require that the old records be kept at hand for six months before disposal. Even if information is not migrated into the new system, it is still important to respect the applicable retention period in the same manner as with paper records. The CMPA recommends that records be maintained for at least 10 years from the date of the last entry or, in the case of minors, 10 years from the date on which the minor reaches the age of majority. Retaining the records will be especially important in the event of a future legal proceeding or College complaint. It is not necessary to maintain the records in their original form (e.g., paper or old EMR system). However, records converted from one format to another (e.g., paper to electronic or legacy system to new system) are considered copies (otherwise referred to as “secondary evidence”) and will be admissible in legal proceedings if certain steps are followed as explained below.
Steps to be followed when archiving a medical record:
Archiving the original record The scanning process creates an unalterable digital image of the original which, if done correctly, will be admissible in a legal proceeding in place of the original paper record. A popular format for a scanned document is Portable Document Format or PDF. Members should, however, be aware of the differences between scanning and using Optical Character Recognition (OCR) software. OCR software creates a searchable and editable file. While the ability to search the file may be useful, the searchable file will not be admissible in legal proceedings in place of the original record. Therefore, OCR alone should not be used, unless the original paper records will also be scanned or will continue to be maintained in paper form. Whether archiving a paper record or records in an old EMR system, the CMPA encourages members to consider the following points to ensure the archived records meet evidentiary requirements:
Archived digital records should be kept in “read only” format so they cannot be altered or manipulated after conversion. When the appropriate steps have been taken, it may be reasonable for you to destroy the original paper record — and free up valuable office storage space. Some Colleges permit the destruction of paper records once they have been scanned. In some cases, however, such as when the quality of the paper records makes the converted document difficult to read, it is prudent to retain paper records for the period of retention recommended by the CMPA. The bottom line
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DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.
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