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Electronic Medical Record (Chart Notes) Note: this is NOT a certified EHRThe EMR (electronic
medical record/Chart Notes) screens and tables are fully integrated with the allergy screens and tables. This is not a 3rd party 'add-on'. It is
a single working system unlike any other software system we have seen.
The Stratford EMR is accessible from the main patient information page. You can print it using a fully customizable format designed for laser printers. If you subscribe to our support we may be able to help you set it up the way you want. It comes with a standard S.O.A.P template that you can use as-is or customize. The EMR screen also displays the allergy tables. It is a very nice system, much better and more usable than some very expensive systems we have seen. Here is more information related to a 'permanent healthcare record' .... The Stratford software was created with a Microsoft database compiler and stores data on your computer's hard drive. All the records can be edited and most can be deleted. The record(s) that the Stratford software creates on your hard drive is not a 'permanent healthcare record'. This is true of most if not all practice management systems. At this time, we recommend that you backup your data onto a CD/DVD -R/+R (not R/W). This type of media is "write once then read only" and as far as we know, it is permanent - there is no way to change it. Most manufacturers of this media specify a lifetime of 40-100 years or more. This should satisfy the requirement for a permanent medical record, but we are not qualified to advise you on that. This is what Stratford uses to backup all data. A CD/DVD can be read and the data restored by most if not all computers sold currently. A backup should be made at least once every day that any changes are made to your data. You should keep the backup at least 7 years in a physical location different from your computer. It is not possible to create a file on a hard drive that cannot be deleted and/or changed, no matter what you may see advertised. As far as we know, no files/records created with any word processing or database software will qualify as a permanent medical record. 'Permanent' is related to the media, not the program that creates the document. Even if you have it encrypted with 256 bit AES, someone could simply delete the file and you would have no record, which would probably be the worst possible situation. As far as hospital records (or other 'permanent' records), there may be a 'flag' on each record that marks that record as permanent. When marked, that program will no longer modify it. It is similar to 'auditing' transactions in the Stratford program. Once you audit a transaction, the Stratford program will not allow you to change that transaction. However, a clever person can still make changes and/or deletions, but not with the Stratford program. In order to truly make it permanent, you must store the data on a type of media that cannot be modified. We believe that the 'secure signature procedure' offered by some vendors is very good. They keep the "private key" and only give out the "public key". Once anything is signed with the "public key", only the "private key" can read it. Of course, their entire security system depends on their ability to keep the private key secret. They have new employees and former employees that at some time have access to that private key. We could add such a flag to the medical record in the Stratford program, but it would only prevent modification by the Stratford program. It might create false confidence that the record was truly permanent. We did this with the transactions, why don't we do it with the EMR? The reason is simple. An accounting record is not necessarily private. You might be amazed how many people have a legitimate reason for having access to your accounting records: auditors, accountants, tax collectors, many government agencies, payers, provider employees, even the patient. The EMR, on the other hand is (or may be) protected by federal law with severe consequences for abuse or lack of care. The provider has a legal obligation to protect the EMR. The EMR is private/confidential. For example, the Internal Revenue Service has no right to see your EMR. It is unlikely that the IRS could get a court order to see your EMR. Enough said - the EMR is private/confidential. The Stratford health record can be printed. If you have a PDF print driver on your computer, it will create a file that is very difficult to modify. It can be printed on almost any printer and will not lose your formatting. We like drivers sold by Adobe and FinePrint pdfFactory and many other 'PDF' writer/drivers. If you backup that file on a CD/DVD -R/+R you will probably have a healthcare record that is as 'permanent' as anything possible with today's technology. Of course, you must store that CD/DVD in a safe location. If you want to be sure, you can have the CD/DVD stored by a certified vendor immediately after saving the data and that certified vendor could guarantee the time that they received CD/DVD. That would guarantee that the information stored on the CD/DVD was not changed after that date. A paper record is accepted by all courts as far as we know. Any other type of record would probably be questioned at this time since electronic medical records are new to most jurisdictions. We do our best to stay up to date on these matters. Stratford has had a contract with EDS to supply software to Medicare contractors (example: NHIC) for 'provider side' billing since 1997. If Medicare and/or other federal government agency should publish specifications for a permanent medical record, we may meet those specs. We appreciate your comments and welcome any feedback. We monitor the www.cms.gov web site regularly to keep up to date with changes in healthcare billing. www.cms.gov is probably the most 'official' source of information. An argument for the electronic health record in the
future. A paper record can be changed at any time. As long as no copies have been made prior to the change, it is possible that the change cannot be proven and this is the reason: many hospitals, healthcare groups and organizations are actively scanning paper records and destroying the originals. There are ways to determine whether a paper record has been changed, however, a scanned image may not contain evidence of the change. A daily backup of an Electronic Medical Record is extremely easy to make. It can be scheduled to occur daily at any given time without human intervention. You can easily make multiple daily backups. You can make hourly backups. A scanned image of a paper record is difficult to create daily at a reasonable cost. The bottom line is that with any healthcare record procedure/system known at this time, it is critical that a permanent copy be made as soon as possible after the record is approved by the author. That copy should be kept in a location at a distance from the original database. The Stratford medical record program is not suitable for storing x-rays and lab tests. It is designed like 'chart notes' such as what a provider might write in a paper chart. Note that the Stratford medical record program is not 'Certified' for the various government incentive programs. At this time we do not plan to have our medical record certified because of the great cost and resources involved. There are many certified programs available now. Many are designed for a specific specialty. We recommend that you do your own research if you are interested in having a 'certified' EHR. We may be able to help you upload your patient information to the EHR that you select. We have written utilities for many EHRs.
Reference:
ed: (scanned vs. 'real/wet' documents): Security newsletters and discussions:
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