Over the past 2 years I have become increasingly involved in information governance and stewardship. This last weekend I had an opportunity to spend some time with colleagues from across Canada who are similarly involved in EMR adoption in their respective provinces.
A policy of the College of Physicians and Surgeons of Ontario (CPSO) was brought to my attention and an excerpt is included below with a link to the full policy as listed on the CPSO web site. What is important is the requirement that the Electronic Medical Record must contain the 'story of the patient'. This suggests that certain EMR systems may be too structured and may not be able to reproduce the history and clinical findings in a way that allows for clear interpretation. In addition, the systems must be able to capture the 'nuances' of the encounters. Any physician will confirm that the ability to capture a narrative is very important in certain circumstances to ensure that nuance is correct and this is sometimes impossible using templates and drop down menus with very structured data entry.
It is very important to remember that policies of licensing bodies and legislation will require a certain level of performance both by the physician and by the system that is being used to capture information. It is these policies and legislative requirements that will govern the way in which performance will be measured if medical legal issues arise or complaints are made regarding care that is provided.
Electronic Records
All of the principles discussed in this policy apply equally to electronic records. The records must contain the story of the patient. While there is some debate about the preferred format of electronic records (e.g., template-based records vs. voice dictation-based records), an electronic format will be adequate if it can capture all the pertinent personal health information and allows the user to centralize the essentials of the patient’s story on several screens. If the format cannot do this, it is probably not satisfactory and the physician should consider using an alternative system.
The College recognizes some limitations of electronic records at the time of writing this policy. In many cases, the printable version of the electronic record does not readily enable a reviewer to understand the whole patient record and is, therefore, of limited use.
Furthermore, some of the systems do not readily allow the physician to capture nuances of the patient encounter. Physicians using such systems must ensure that each record entry captures the unique aspects of that particular patient encounter. The College is aware that this is a developing area and that there is great potential for electronic record keeping to enhance the practice of medicine.
Physicians have an obligation to provide printed copies of electronic records when asked to do so. In order to ensure they can be understood, some physicians provide the print-out from the electronic record together with a dictated summary to provide an overview of the patient’s story.
Specific requirements for physicians who maintain electronic patient records are set out in sections 18-21 of Ontario Regulation 114/94, listed in Appendix A
The College notes that residents frequently retain patient information on PDAs and laptops in order to track workload and for educational purposes. Issues about storage, deletion of records and privacy of health information can pose the same problems in this context as discussed elsewhere in this policy, and those who are using records in this fashion are cautioned to ensure that they are doing so in adherence to the policy.
Link: Policy- Medical Records
As a user of an EMR system or someone considering the purchase and implementation of an EMR, have you considered the College requirements in your province relating to Electronic Medical Records? Recognizing that this is currently in evolution, would you like to be kept up to date on developments in this area? Have legislative and governance requirements been on the radar for you or is there too much noise out there that is difficult to sort out as you run a busy medical practice?
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