By Peter Polack

A good electronic medical records system must be able to demonstrate a process for maintaining the legal integrity of its records. Here we cover some of the top considerations when moving your practice from paper to digital.

As a practice makes the transition from paper to electronic medical records, they may encounter a variety of legal concerns. Some important decisions must be made to ensure the legal integrity of digital records. Additionally, there will be some surprises in store regarding compliance, privacy, and security. In matters of electronic medical records, the best offense is a good defense. Here are some issues to consider:

When you write a medical exam on a piece of paper and sign it, you’ve created a legal document. By now you are probably well aware of the importance of documentation, and the dangers which alterations to medical records invite. A paper chart’s integrity is usually rather simple to determine. However, an electronic chart is often more complicated. According to the Healthcare Information and Management Systems Society, an electronic record must be stored in a legally correct manner - otherwise it may be considered hearsay, challenged as legally invalid.

So, why is this important? Well, if your electronic medical records don’t meet the Federal or State requirements for a medical record, payors can deny a claim. Or, even worse, you may subject your practice to an increased risk of an adverse outcome in litigation. It’s not only important to be sure your electronic medical records are not altered, but you also need the ability to demonstrate the procedures which prove this fact.

How do you make sure an electronic record cannot be altered? The ideal system must balance the user’s desires, including ability to correct mistakes and make changes, with the legal integrity of the record itself.

- Does your EMR system “time stamp” each entry to produce an audit trail? This could include an unalterable record of every entry and event in order to prove the validity of the record.

- Does it restrict access to certain templates or features? You wouldn’t want a front desk employee changing patients’ intraocular pressures, for example.

- Does the system keep track of which person documented what? You wouldn’t want your name associated with another user’s entry.

- Does it have a strict but not too time-consuming security protocol? Some solutions include alphanumeric passwords that are changed periodically, biometric access, and automatic logout after a period of inactivity.

- Does it have a secure yet practical “lock-out” feature? A typical one might allow the doctor to make changes at the end of the day, but after 24 hours the record locks. This may seem a bit harsh, but it could actually serve to protect you by preventing unauthorized changes.

Above article publish on http://www.buzzle.com/articles/some-of-the-legal-issues-with-electronic-medical-records.html