Comments on: Legal Issues of the Electronic Medical Record

By: CJ Cossette

CJ Cossette — Tue, 20 Jul 2010 01:48:04 +0000

Great article…..In my opinion, the security procedures of the EMR/EHR have to be “tried and true”, with a secondary approach to maintaining that security. Although a third party is a possibility, many health care organizations (i.e. hospitals) today are cash strapped. It is up to those cash strapped organizations to implement the EMR/EHR standard operating procedure in-house.

Another issue I see is the in-patient vs. out-patient debate. If the decision is to maintain a long series of outpatient visits rather than one inpatient stay, I see a greater risk of errors to that record and with that comes a lack of security.

By: Peter Polack

Peter Polack — Tue, 01 Jun 2010 23:36:12 +0000

Eric, thanks again for a concise explanation of another one of many legal issues regarding electronic medical records. This illustrates the reason why, although many EMR software systems may allow a physician to ‘unlock’ a record and make changes, such changes may cast doubt on the integrity of the patient record. Another example would be a physician allowing medical assistants to log in or out using the physician’s password for the sake of expeditiousness.

By: Eric Rossborough

Eric Rossborough — Tue, 01 Jun 2010 19:36:34 +0000

Nice article.
An important consideration in ensuring your electronic medical records system is legal and defensible, is to make sure that the information can be authenticated by a trusted third party.
Why a trusted third party? You need to be able to illustrate the information’s integrity. If the electronic data is used in court the evidence rules still apply. Just like with paper records. (See Federal Rules of Civil Procedures even though these are federal rules, most states apply them as well.) The digital information could be subject to prove it’s authenticity. (Rule 109 of the Federal Rules of Evidence.) An example of this is Vee Vinhnee v. Amex -CA 2005. In this case, American Express claimed Vinhnee failed to pay credit card debts and took action to recover the money. After a trial that occurred in the absence of the defendant, the trial judge determined that American Express failed to authenticate certain records in digital format. American Express appealed the verdict, and the decision of the trial judge was affirmed. Judge Christopher Klein remarked,
” …the focus is not on the circumstances of the creation of the record, but rather the circumstances of the preservation of the record during the time it is in the file so as to assure that the document being proffered is the same as the document that originally was created.”
It is best to be able to show the: WHO created/edited the file, WHAT the file is and WHEN was it created/edited.
(Please got to: http://www.Tru-DataIntegrity.com for more information.)
I look forward to seeing more on this interesting topic.

By: uberVU - social comments

uberVU - social comments — Mon, 08 Feb 2010 14:12:57 +0000

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By: Jayanta Bhowmick

Jayanta Bhowmick — Mon, 04 Jan 2010 09:34:58 +0000

good article. All HIMMS and EMR should create legally valid documents when required in the court of Law.