What’s the same?
To make sure electronic records are safe and secure, all Colleges require that there are systems to ensure:
- The correct record is accessed (e.g. by unique identifier)
- Records are retrievable, which may include printable, visual display
- Records are secure from loss, tampering and unauthorized access
There are also other considerations for electronic records, such as:
- allowing changes to records while making sure the original content is preserved
- creating an audit trail of who accessed or made changes to a record for future reference
- using physical controls, passwords or encryption to maintain privacy and confidentiality
- ensuring chronology is reflected in printed versions
- regularly and automatically backing up information
- ensuring patient specific information can be captured and avoiding template-like records
- allowing more than one author to sign, where appropriate
There are no significant differences between the Colleges. We all need to protect electronic health information.
In time, Willow Pines decided to move to an electronic documentation system. All members of the inter-professional team are excited about the efficiency this move will bring but are worried about meeting College requirements. They each review their College’s resources and create a comprehensive list of requirements that they share with the clinic owner. Together they work with the technology provider to ensure they can meet College and PHIPA requirements and protect patient information.
The Office of the Information and Privacy Commission Ontario has two resources that may offer practical assistance:
- Tool for Physicians Transitioning from Paper-Based Records to Electronic Health Records
- Embedding Privacy into the Design of Electronic Health Records