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Electronic Health Records

Electronic Health Records. Agenda. Paper vs. electronic records Legal issues Email and PHI Records retention and destruction. Paper vs. Electronic Records. Legal health record Contents of a paper medical chart along with radiology films and other imaging

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Electronic Health Records

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  1. Electronic Health Records © 2009 Cengage Learning. All Rights Reserved.

  2. Agenda • Paper vs. electronic records • Legal issues • Email and PHI • Records retention and destruction © 2009 Cengage Learning. All Rights Reserved.

  3. Paper vs. Electronic Records • Legal health record • Contents of a paper medical chart along with radiology films and other imaging • Must meet federal and state law standards • Must meet CMS and healthcare accrediting agency requirements © 2009 Cengage Learning. All Rights Reserved.

  4. Paper vs. Electronic Records contd. • Electronic health record (EHR) • Computerized format of a patient’s paper health records • Part of health information technology system • Consists of integrated information systems and technologies, with different data and images © 2009 Cengage Learning. All Rights Reserved.

  5. Federal Laws and Preemption • HIPAA • Enables electronic health records • Preempts any state law that conflicts • E-SIGN • Puts electronic signatures and records on par with paper • Preempts any state law that conflicts © 2009 Cengage Learning. All Rights Reserved.

  6. State Licensure for Any Health Records • Defines required contents of patient charts • May also have requirements for EHR as long as they don’t conflict with HIPAA and E-SIGN © 2009 Cengage Learning. All Rights Reserved.

  7. Accreditation Issues • Voluntary accreditation (e.g., Joint Commission, NCQA) • CMS requirements • Electronic prescriptions © 2009 Cengage Learning. All Rights Reserved.

  8. Legal Issues in EHR • Authentication • Provider documentation • Admissibility • State law and rules of evidence • Hearsay • Best evidence rule © 2009 Cengage Learning. All Rights Reserved.

  9. Email and PHI • HIPAA Privacy and Security Rules for EPHI • Electronic Privacy Communication Act • Common problems associated with Internet © 2009 Cengage Learning. All Rights Reserved.

  10. Records Retention and Destruction • State law requirements for retention of different types of records • CMS requirements for patient records • Business practices © 2009 Cengage Learning. All Rights Reserved.

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