After several years of hearing so many conflicting ideas about going paperless and electronic medical records, I decided to explore the topic for myself. For those who pursue a paperless system regardless of the legal requirements the options are endless. I hope to help focus your research. Feel free to contact me with any questions.In the coming weeks I hope to answer all your questions about electronic medical records, the legal standards that govern them, how patient privacy affects your use of technology and finally the software and hardware involved. For many of you the answers I offer in this first week will decide if you convert to a paperless system.
Disclaimer: I am not an attorney. I am not liable for any content, errors or omissions or inaccuracies. I cannot make any guarantees about the content. Please, please get legal services when you need them, they are the experts!
Electronic record terminology
First I’d like to clarify two terms that I often see used interchangeably when they are separate concepts.
Electronic medical records (EMR) are tied to an individual provider, it has exactly what the paper chart in our offices does, but is digital. On the other hand an electronic health record (EHR) has a wider umbrella. An electronic health record centers on the patient, it follows them from provider to provider, eases communication between providers and creates an overall picture of the patient’s health.
Am I legally required to adopt electronic records in my clinic?
Surprised? Me too. Nearly every practitioner I’ve talked to recently believed this is something all heath care providers had to implement OR that acupuncturists are exempt from the “requirement.”
This, of course, is not a simple no. While I found several secondary sources[ref]J Lynn. (2011, Jan. 13). 2014 EHR mandate. Retrieved from http://www.emrandhipaa.com/emr-and-hipaa/2011/01/13/2014-ehr-mandate/[/ref][ref]Rosen, T. (2010, Winter). Payments (and Penalties) for Electronic Health Records. Mid-Atlantic Health Law TOPICS. Retrieved from http://www.gfrlaw.com/pubs/GordonPubDetail.aspx?xpST=PubDetail&pub=836.[/ref] that spoke of this I went right to the source.
There are several laws involved. The first comes from the American Recovery Act of 2009. Also known as Public Law 111-5, title XIII and title IV are commonly called the Health Information Technology for Economic and Clinical Health (HITECH) Act (PDF). The other federal law that addresses electronic records is the Affordable Care Act (ACA) of 2010 (PDF) (click on the links for full text).
After reading the HITECH Act and thoughtfully searching the ACA (it’s a 900+ page law) I found that the language of the law does not legally require use of electronic medical records.
Section 3006 of title XIII in the HITECH Act lays it out very clearly:
The exception found under 13112:
Currently acupuncturists and other holistic practitioners are not Medicare or Medicaid providers, so they do not qualify for any of the incentive programs outlined in the HITECH act. While there is discussion of our inclusion into medicare and medicaid this is not the case at the moment. In addition, most of us do not have contracts providing healthcare for government sponsored or administered programs.
If you’re not an eligible medical professional then, as far as I can tell you have no legal obligation to implement an electronic records system.