The protection of confidentiality is a key concern relative to the use of Electronic Health Records [EHRs] and as a result, concurrent with the continued focus on confidentiality is the push to increase the use of electronic medical records. One of the more recent releases by the Centers for Medicare and Medicaid Services [CMS] described the approach for its surveyors to follow when electronic health records are in use at the site being surveyed.

Providers are expected to orient the surveyor to its EHR system and to provide one individual to assist the surveyor with access to the system, as well as to provide answers to questions that might arise during the onsite survey process.

In addition, the provider is to provide a terminal for the surveyor to use in order to access the EHRs at each care location. Surveyors are also to be provided access to printers that can be used to print the entire or any part of the EHR being reviewed, if the surveyor so desires. It is suggested that it would also be a good idea to provide the surveyor with access to read only EHRs in order to assure that unintentional changes are not made into the original record.

Surveyors are directed to only print out record components that directly support findings of noncompliance and are instructed to assure that the patient’s right for confidentiality of his personal health information is maintained. Should a surveyor have concerns relative to compliance with the HIPAA regulations, the surveyor is responsible for reporting this concern via the complaint reporting process to either the Office of Civil Rights [OCR], or to the CMS Office of eHealth Standards and Services, in keeping with the type of concern identified.

Providers should note that the surveyor is directed to maintain a consistent approach to the survey process and determination of compliance with the Conditions of Participation [CoPs] for all surveys, regardless of whether the provider uses electronic or paper based record systems.

The goal, established by the Department of Health & Human Services (HHS) is that by at least 2014, most Americans will have access to health care providers who offer and use electronic health records. It is anticipated and believed that by using EHRs, there will be better patient/client/resident care, reduced costs to providers, and reduced costs to Medicare and Medicaid programs. However, it is not mandatory at this time that all providers and suppliers switch to electronic health record systems.

During the entrance conference, which is one of the first steps in an onsite survey, the surveyor is directed to determine if the provider is using EHRs and if so, the surveyor is directed to follow the process outlined in this release.

Providers can access the complete information provided to surveyors in this release by going to http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter09_53.pdf.