EHR (Electronic Health Record) & Legal Aspects

By Abdulla Israr & Simran Rani

EHR (Electronic Health Record) & Legal Aspects


Introduction

  • EHR is a digital version of a patient's paper chart.
  • It contains real-time, patient-centered records accessible instantly and securely to authorized users.
  • Includes medical history, diagnoses, medications, immunization dates, allergies, lab results, radiology images, and more.
  • Promotes coordinated and evidence-based care.

Computerization of Medical Records

  • Involves transforming paper-based records into digital format using software systems.
  • Modules: Patient registration, clinical notes, laboratory, radiology, billing, discharge summaries, etc.
  • Integrates with Hospital Information Systems (HIS) and other departments for seamless information flow.
  • Enables quicker access, easier storage, and data analytics for quality improvement.

Implementation of EHR

  • Steps:
    1. Need Assessment: Identify hospital requirements.
    2. System Selection: Choose suitable EHR software.
    3. Planning & Budgeting: Infrastructure setup and cost planning.
    4. Data Migration: Convert and import existing paper/legacy data.
    5. Training: Train doctors, nurses, MRD, and admin staff.
    6. Go Live & Monitoring: Implement in phases, monitor for issues.
  • Key Players: IT Team, Medical Records Department, Hospital Admin, Software Vendors.

Maintenance of EHR

  • Regular software updates and security patches.
  • Data backup protocols to prevent loss.
  • Continuous user training and support.
  • Performance monitoring to avoid system failures.
  • Ensuring compliance with data protection regulations.

Challenges

  • High initial cost (software, hardware, training).
  • Resistance to change from staff.
  • Data privacy and security concerns.
  • Lack of IT infrastructure in smaller facilities.
  • Technical issues like downtime or software bugs.
  • Poor inter-departmental integration.

Limitations

  • Dependent on electricity and internet.
  • Possible data breaches or cyberattacks.
  • Can lead to "information overload".
  • Risk of medical errors if data is incorrectly entered.
  • May cause depersonalization in patient care.

Standards in EHR

  • HL7 (Health Level Seven): Standard for electronic data exchange.
  • DICOM: Standard for handling, storing, printing, and transmitting medical images.
  • ICD-10/11, SNOMED CT: For disease coding and classification.
  • ISO 18308: Functional requirements for EHR architecture.
  • HIPAA (USA) / DISHA (India – proposed): Laws for protecting health information privacy.

Administrator’s Role in Computerization

  • Planning and budgeting for EHR systems.
  • Selecting appropriate vendors and ensuring customization.
  • Ensuring training for all departments.
  • Policy formulation on data access and security.
  • Coordinating between departments and IT teams.
  • Monitoring performance and addressing grievances.

HIPO Chart (Hierarchy plus Input Process Output)

  • A tool for analyzing and documenting system processes.
  • Helps in mapping the flow of data in computerized systems.
  • Useful for designing EHR and other health information systems.
  • Represents hierarchy of functions and their corresponding input-process-output.

Computer Linkages

  • Intra-hospital: Link between departments – MRD, Lab, Pharmacy, Billing.
  • Inter-hospital: Referral hospitals, insurance agencies, government portals.
  • External: Telemedicine platforms, health apps, national health databases.

Advantages of EHR

  • Improved patient safety and care quality.
  • Real-time data access by multiple users.
  • Reduces medical errors and duplicate tests.
  • Efficient use of hospital resources.
  • Better clinical decision support and analytics.
  • Legal protection through complete documentation.

Legal Aspects in Medical Records

Medical Negligence

  • Failure of a healthcare provider to provide standard care, leading to harm.
  • Medical records serve as key evidence in negligence claims.
  • Incomplete or manipulated records can indicate malpractice.

Importance of Documentation

  • Legal proof of care given.
  • Supports clinical decision-making and continuity of care.
  • Used for audits, insurance claims, legal cases, and quality control.
  • Must be accurate, timely, legible, and complete.

Indian Penal Code (IPC) 1860 & Medical Records

  • IPC Section 197: Protection for public servants including doctors, acting in good faith.
  • IPC Section 304A: Deals with death caused by negligence (can be applied to medical negligence).
  • IPC Section 201: Destruction of evidence (applies to tampering with medical records).

Guidelines for Medical Record Completion

  • Records should be completed within 24–48 hours of patient discharge.
  • All entries should be dated, timed, signed with name and designation.
  • No overwriting – corrections with single line and countersigned.
  • Use standard formats like POMR, SOAP notes.
  • Confidentiality must be maintained – access only to authorized personnel.

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