Standards and requirements for electronic health records systems remain in active development through the continuing efforts of multiple organizations including ASTM, HL7, and HITSP. Currently, though, the burden of proof (and risk) that a given EMR meets comprehensive requirements remains entirely on the purchaser. Furthermore, there are few resources for those who do take the time to execute a more robust due-diligence effort in comparing and contrasting higher level attributes as part of their selection process.
The Medical Records Institute, in association with recognized experts in EMR functional assessments, have developed a new initiative to highlight key attributes of EMRs to support fundamental medical-legal requirements of medical records as business records. This initiative grew out of concerns about purchaser and user awareness of medical-legal gaps in health IT, including assuring that an EMR can meet basic requirements such as retention of the original version of an altered record as required by medical records best practices and standards such as the American National Standard ASTM Designation: E 2017 – 99 (Reapproved 2005) Standard Guide for Amendments to Health Information. EMR developers note that such requirements are often absent from purchaser/user demands.
While undoubtedly requirements will become increasingly robust over time, the push to implement EMRs, especially in the United States, has made these basic medical-legal gaps all the more risk-laden for those who may not fully evaluate systems they are buying, and who may not fully mitigate gaps in their current systems’ abilities to support such basic medical records functions.
By highlighting the existence of EMRs that are well-designed in their support of these attributes, it is hoped to improve market transparency for medical-legal requirements as a core requirement for EMRs, thereby facilitating both improved selection and implementation of EMRs and speeding the uptake of systems by reducing their potential medical-legal risk.
This new TEPR Award is the first major effort to challenge EMR vendors to demonstrate that their products meet a range of EMR medicolegal requirements, including identity and authentication, document version management, signature events, data integrity and document event auditing functions.
Candidates for the award (who must be TEPR exhibitors) will complete a questionnaire designed by a team of independent attorneys, legal experts, and EMR and health information management professionals. For more information about TEPR and the TEPR awards see www.TEPR.com or contact Claudia Tessier: Claudia@medrecinst.com. Vendors seeking information about TEPR exhibits should contact Michael Lawrence at 617-964-3923 x217 or Michael@medrecinst.com.
