The use of electronic medical records (EMRs) is a virtual mandate for Canadian medical practices. They increase efficiency, save lots of money, and help doctors and medical assistants do their jobs better. However, the growing prevalence of EMRs also means that a new set of government policies have inevitably arisen. This means that you will have to change the way that you manage your EMRs in order to comply with these new policies.
Unfortunately, there is no magic wand you can wave that will automatically put your EMR management practices in sync with the law. Fortunately, keeping up with electronic medical records policy does not have to include turning your entire practice upside down -- if you know what steps to take. Figuring out what steps to take to comply won't be a problem for you either, because we are going to explain what you need to do in this article.
Provide access to all relevant medical records when a request is made by the proper authorities
As you would expect, electronic medical records policy requires you to be able to provide the Canadian government with access to EMRs upon request. All of the information that you must provide is still listed by the Medicine Act of 1991.
While EMRs have not changed what you need to submit, they have changed how you must submit medical records. More specifically, the College of Physicians and Surgeons of Ontario (CPSO) requires that everything is legibly written. To clarify, let's take a look at the two primary requirements for legibility:
Avoid abbreviations
If your medical records cannot be read by anyone but you and your cohorts, then they won't be of much use outside of this relatively small circle. This is why you should avoid abbreviations.
Convert handwritten prose into something legible
People outside of your practice shouldn't have to strain to read your medical records. That is why you are required to convert your handwriting into something readable by anybody. This isn't as difficult as you might think either. You won't have to type up everything that you have written. Instead, a good scanning software solution can automatically convert most of your handwriting into typed documents.
Double check all medical records for accuracy
One thing that EMRs have enabled health practitioners to do is create unified health records created by multiple practices. However, a health record controlled by multiple practitioners can make it difficult to determine who did what.
According to the CPSO, Canadian policy states that in order to reduce confusion, you are only responsible for medical records controlled by your own health practice (assuming that you have limited control over the EMR due to multiple practitioners being able to access it). You should know, however, that the ease with which you can create virtually flawless medical records with EMRs has raised expectations for the quality of the records that you keep available. In fact, they need to be 100 percent accurate to make the grade. This includes recording "the start and stop time for certain types of patient encounters, such as psychotherapy and counselling.” Also, records must be completed as quickly as possible "especially in coordinated care environments.”
Since you can double check EMRs for accuracy with only a few clicks (assuming that you are using good records management software), this should not be difficult to comply with.
EMRs make everything easier, even following the law
Just because electronic medical records policy is different does not mean that it will make your job more difficult. In fact, once you implement best practices for compliance, you will discover that it actually makes things easier.
