The following article addresses a topic that we have written about in a previous edition of the ºÚÁÏÉç Connector, ownership of patient records. This topic continues to cause concern for registrants who share access to patient records. The context of these situations usually involves a difficult transition such as the abrupt loss of a colleague due to illness or a relocation.
Registrants who work in a setting where access to medical records is shared must have a formal contract, which is agreed to and signed by every registrant who makes entries into patient records.
The ºÚÁÏÉç practice standard Medical Records Management is very clear:
In all situations where a registrant is creating medical records in a group or shared medical record environment, a data-sharing agreement must be in place which addresses how issues of ownership, custody and enduring access by individual registrants and patients will be addressed, including following relocation, retirement or death of the registrants. Where a registrant creating a medical record is not the owner of the clinic and/or of the electronic medical record (EMR) licence, issues of custody, confidentiality and enduring access by individual registrants and patients must be documented in a formal contract with the owners and/or EMR service providers.
Based on the number of registrants who disclose that there are no such contracts in place in their practices, the ºÚÁÏÉç is reminding registrants once again of their duty to comply with the expectations set out in practice standards, which are enforceable under the Health Professions Act.
Another valuable resource worthy of sharing again comes from the CMPA:
Clarity over control and stewardship of information in a shared practice arrangement can be achieved by entering into a data sharing agreement or inter-physician arrangement. The CMPA’s includes data sharing principles for EMR/EHR agreements as well as a template agreement that can be used as the basis for developing a data sharing contract with another party (such as hospital, health region, or service provider) or with other physicians.
The Divisions of Family Practice (Family Practice Services Committee) have posted sample contractual terms on their website: . Doctors of BC and the ºÚÁÏÉç strongly recommend seeking counsel from a lawyer.
When disputes arise in the absence of a contractual agreement, registrants must resolve their issues collaboratively, and with no impact to patients. Access to records required to inform the care of a patient must never be impeded. In the event of a patient complaint, registrants practising without a data-sharing agreement, clinic owners and medical directors may anticipate criticism.
Registrants should consider declining to work in clinics where a data-sharing agreement is not in place. The ºÚÁÏÉç standard advises registrants already engaged in patient care in such a setting to seek the advice of a lawyer, if need be, to ensure the issues are fully addressed.
Heidi M. Oetter, MD
Registrar and CEO
Comments on this or any other article published in the ºÚÁÏÉç Connector can be submitted to the communications and public affairs department at communications@cpsbc.ca.