The College continues to receive numerous calls from distressed registrants inquiring about ownership of patient records. The context is usually a difficult transition: for example, one or more physicians relocating to another clinic, or the abrupt loss of a colleague due to illness. In these circumstances, it is not a good time for sorting out responsibility for and access to patient records. Such matters must be agreed to in advance and formalized in contracts signed off by every registrant who makes entries into shared records.
The College practice standard Medical Records, Data Stewardship and Confidentiality of Personal Health Information 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.
College standards have the force of law under the Health Professions Act, RSBC 1996, c.183. Based on the number of callers who advise that there are no such contracts in place in their practices, it appears that a very large number of College registrants are in breach of the standard. I urge all of you to take steps to ensure that you and your colleagues come into compliance without delay.
The CMPA provides similar direction in an article “Who has custody of medical records, and who can they be shared with?”
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 Agreement. The CMPA’s Electronic Records Handbook [PDF] 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 (General Practice Services Committee) have posted sample contractual terms on their website: Medical Records – Issues and Guidelines. They recommend consultation with a lawyer as does the College.
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 College 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
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