Converting paper records to electronic form
To help ensure paper records converted to electronic format meet legal requirements:
- Written procedures should be established and consistently followed for the conversion (including a record of the type of conversion process used), with the physician keeping a copy of these procedures. A reputable commercial organization may assist in establishing procedures for the conversion.
- The conversion should take place in a consistent and careful manner, with appropriate safeguards to ensure the digital copies are reliable.
- The process should involve quality assurance (e.g. comparing the digital copy to the original to ensure the information has been accurately converted), and a record should be kept of the quality assurance steps taken.
Developing and implementing policies
When incorporating an eRecord system into a medical practice:
- Office policies should be established to govern issues such as data integrity, consent, security, access, and transfer and destruction of records.
- In a group practice, policies might be developed as a team to ensure all staff members are engaged in the process and aware of the importance of privacy in the eRecord environment. Staff should be appropriately trained to ensure they understand the policies and their obligations.
- The policies should be applied consistently and in keeping with underlying privacy principles.
Destruction of paper records
Most, if not all, Colleges permit the destruction of paper records once they have been appropriately scanned. When the appropriate steps have been taken, it may be reasonable to destroy the original record in a manner in keeping with physicians’ obligation of confidentiality as well as any applicable legislative and College requirements. In exceptional cases, such as when the quality of the paper records makes the converted document difficult to read, it may be prudent to retain the paper records for at least the period of retention recommended by the CMPA.
Scanning and optical character recognition (OCR)
Scanning generates a non-editable digital representation of an image whereas OCR is a technology process that converts an image of handwritten or typewritten text into machine-editable text. OCR alone should not be used when converting paper records to electronic form, unless the original paper records will be scanned or will be maintained in paper form.
Legal status of eRecords
Documents converted to electronic format are considered copies. However, they are nonetheless generally admissible in legal proceedings. In most Canadian provinces and territories, the rules concerning the admissibility of copies take into account the reality of electronic record-keeping.
Responding to a legal request to produce an electronic record can be challenging. It may be necessary to produce the “metadata” embedded in all electronic documents, including the audit trail, records of key strokes and deletions, and decision support information. Specialized technical assistance may be needed to ensure that all the required data is included.