InformationWeek, August 18, 2011

An electronic health record is more than just an electronic representation of a paper chart. It is a legal representation of a patient's medical condition and treatment at a given point in time, one that could be admissible in court. And that could present a whole new set of challenges for healthcare organizations. "There is no guide out there to walk people through all that changes with an EHR," Adam Greene, a Washington, D.C.-based partner in the law firm of Davis Wright Tremaine, said this week at the American Health Information Management Association Legal EHR Summit in Chicago. EHRs make patient information more readily accessible to far more people than any paper chart stashed away in a filing room. They also change how and to what extent medical professionals document patient encounters and add in safety-related features such as clinical decision support. "There are all sorts of liability fears with all these improvements," Greene told InformationWeek Healthcare. The Health Insurance Portability and Accountability Act privacy and security rules require anyone that handles electronic healthcare data to keep an audit log of access to any personally identifiable information, and records have helped organizations catch employees taking unauthorized looks at patient records--sometimes also landing the organizations themselves in hot water.

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