Electronic records handbook

Table of contents

eRecords at a glance

  1. Physicians should be familiar with the legislation, regulatory requirements, and technological features and standards that apply to eRecords.

  2. An eRecords system should meet the needs of a physician’s practice and comply with applicable legal and regulatory requirements. See “Requirements for eRecord systems and physician obligations.”

  3. Physicians should consider having an agreement for a shared electronic medical record (EMR) or electronic health record (EHR). The CMPA’s Data Sharing Principles and the template Contractual Provisions for Data Sharing, can serve as a model. As well, employees should sign a Confidentiality or Non-disclosure Agreement that outlines their obligations to keep patient information secure and confidential.

  4. Physicians should understand their obligations when they participate in an EHR system or when asked to upload portions of their office EMR to an EHR operated by hospitals, regional health authorities, provinces or territories, etc. See “data-sharing.”

  5. Physicians should consider speaking with patients about including personal health information in an eRecord. Patients’ express consent may be necessary when their personal information is shared with others for purposes other than providing healthcare (i.e. outside the circle of care). See “Patient consent and right to access records.”

  6. Security requirements of eRecords are essential and include secure backup, encryption of personal health information, audit trails, and access control. See “Information security, confidentiality.”

  7. Retention periods are just as important with eRecords as they are for paper records. Once the required retention period has expired, the information in the eRecord can be appropriately destroyed. See “Destroying and disposing of records.”

  8. Physicians will want to assess the implications of relying exclusively on patient-supplied electronic personal health records (sometimes referred to as “patient health records” or PHRs). See “Related digital health technology.”