[Gnumed-devel] EMR requirements in one Canadian province

[Jim Busser]

From

http://www.ipc.on.ca/images/Resources/phipa-toolforphysicians.pdf (page 10)

In the Province of Ontario (not my own, which is British Columbia):

... while legislated requirements have yet to be developed, the IPC fact sheet,  Safeguarding 

Personal Health Information, suggests that, where electronic health records are kept, custodians 

should ensure the following: 

• The use of features such as strong passwords to prevent unauthorized access; 

• The installation of automatic backup for file recovery to protect records from loss or  

damage; and 

• The creation and maintenance of an audit trail that, at a minimum: 

Records the date and time of each entry for each patient; 

Shows any changes made to the record; and 

Preserves the original content when a record has been changed, updated or corrected. 

Ontario Regulation 114/94 made under the Medicine Act states that the medical records required by regulation may be made and maintained in an electronic computer system only if it has the following characteristics: 

The system provides a visual display of the recorded information.

The system provides a means of access to the record of each patient by the patient’s

name and, if the patient has an Ontario health number, by the health number. 

The system is capable of printing the recorded information promptly.

The system is capable of visually displaying and printing the recorded information for

each patient in chronological order.

The system maintains an audit trail that:

records the date and time of each entry of information for each patient 

indicates any changes in the recorded information

preserves the original content of the recorded information when changed or

updated, and 

is capable of being printed separately from the recorded information for each 

patient. 

The system includes a password or otherwise provides reasonable protection against 

unauthorized access. 

The system automatically backs up files and allows the recovery of backed-up files or

otherwise provides reasonable protection against loss of, damage to, and inaccessibility 

of, information.