Electronic records handbook

Table of contents

Related digital health technology

While eRecords continue to evolve with new functionality, emerging digital health innovations may also present medico-legal issues.

Decision support systems

Some eRecords systems include decision support tools that prompt the user to consider certain factors or possible decisions in response to the inputted data. The software may also include alerts, flags, or instant messaging capabilities to assist physicians in diagnosing, treating, and monitoring their patients’ clinical conditions or managing their prescriptions.

A decision support tool in an eRecord may present unique and challenging issues. For example, physicians should determine if the system permits individual users to disable or disregard the decision support tool. If this is the case, doctors will want to consider the availability of a robust audit trail that tracks the advice that is accepted or rejected. Although each system functions differently, users should know in advance how the particular decision support tool operates and whether the information generated is reliable.

Decision support tools must not be used to replace a physician’s own judgment. Each suggestion offered by the decision support tool should be reasonably considered and assessed based on the circumstances of each case.

Physicians will want to consider documenting in the patient’s record their reasons for following or ignoring a suggestion provided by the decision support tool or for acting on or disregarding an alert, flag, or instant message. If the diagnosis suggested by the software was ignored and proves in hindsight to be accurate, the physician may be required in the course of a legal action or College complaint to justify why the information was disregarded.

Similarly, ignored alerts, flags, or messages notifying the physician of abnormal test results or prescription errors could be used as evidence of negligence or professional misconduct in civil or College proceedings. Documentation of the physician’s rationale for disregarding a suggestion or notification would be helpful in the event of a College complaint or legal action. Similarly, if the decision support tool is disabled, physicians will want to document their rationale for doing so.

Patient health records

Unlike an EMR or EHR, which is typically created and maintained by a healthcare professional or facility, a patient health record (PHR) commonly refers to a compilation of information (including past and present medical conditions, medications, and allergies) that has been personally gathered and maintained by the patient using a third-party service.

Patients may choose to grant physicians and other healthcare providers access to the information entered into their PHR. Many products allow hospitals, clinics, laboratories, pharmacies, and individual physicians to upload additional health information into the PHR. Patients can also upload data, such as blood pressure readings, temperature, or blood sugar levels.

While information from PHRs may be added to the medical record and can help inform clinical decision making, physicians should be cautious about relying on it exclusively and may choose to verify its accuracy. The source of the data (e.g. patient) should be included in the medical record.

PHRs should not be considered a replacement for a physician’s own record-keeping, nor should they replace a physician’s assessment of patients including asking direct questions about a patient’s medical history.

When a patient asks a physician to upload information to a PHR, the physician should discuss the request with the patient, and carefully consider issues about consent and security.

Patient portals

Online patient portals allow patients to securely communicate with their physician, easily view their medical record and do such things as request appointments and prescription renewals.

The CMPA generally recommends that physicians include terms of use on the patient portal, which clarify expectations and outline the terms and conditions under which patients may access the portal and how it will be used. For more information about patient portals, see the CMPA article, “Patient portals—Considerations for safety and medico-legal risk.”