How Can I Ensure My EHR System Is Compliant with Current Regulations?

An electronic health record (EHR) system has become one of the most valuable resources for today's medical practices, providing a streamlined way to ensure patient information is managed effectively. It allows providers across various types of care to have a comprehensive view of a person's medical care, which could influence the outcome.

Yet, in every situation, we must ensure EHR systems remain compliant. Regulations provide confidentiality and privacy protection for patients, especially since these records contain some of the most intimate details of a person's life. Adoption of a compliant EHR system may seem overwhelming, but once you learn it and keep it current, the implementation of these systems is incredibly valuable.

Learn the Standards Required for Electronic Health Records Compliance

For any person within the practice, the first step is ample training on best practices for ensuring EHR system regulation compliance. A solid starting point is to read and understand the Compliance Program for Electronic Health Records Fact Sheet from the Centers for Medicare & Medicaid Services. This document outlines the specific policies and procedures that all practices must follow to ensure compliance with relevant regulations.

Additionally, for compliance guidance, refer to the U.S. Department of Health and Human Services Office of Inspector General. This describes a voluntary compliance program that can provide nursing homes, medical centers, third-party billers, and medical equipment suppliers (along with other practice types) with a complete understanding of their obligations. You can find specific compliance program guidance documents for all necessary rules. These are kept up to date, providing an excellent source for verification.

How to Ensure EHR System Regulation Compliance

Keeping compliance guidelines readily available in your practice is essential, but regular updates are necessary to ensure everyone remains up to date. To verify your practice's compliance with current regulations, consider these critical strategies:

Conduct a Compliance Audit

You can't improve what you don't know is wrong. Begin with a comprehensive audit of the existing software. Look for specific gaps or areas of non-compliance. This may include specific areas such as:

• Security feature use or misuse

• Audit trail functionality within the system

• Encryption capabilities

• Access controls

Organizations can also partner with an electronic health records consultant to facilitate streamlined, efficient audits. Having a third party handle this audit may open the door to more mistakes.

Implement User Authentication and Access Controls

A critical step in ensuring compliance is ensuring that user authentication and access controls are applied and used consistently throughout the practice. This should include:

• Unique passwords and usernames for each individual

• Access control for various types of employees through role-based controls

• Regular password changes

Authentication measures like this create a vital blanket level of protection for everything in a patient's file. It also helps ensure practitioners can go back and verify what was updated, who did it, and when it was done, all critical components to effectively managing an electronic health record.

Staff Training on Ensuring EHR System Regulation Compliance

Working with an electronic health records consultant to provide staff compliance training is also valuable. This can be done on a routine basis, ensuring that new updates or changes in regulations are clearly understood and implemented promptly. Staff typically need training in areas such as:

• Data access

• Patient information sharing and handling

• Disclosures

• Maintaining patient confidentiality

Complete Routine Assessments of Risk

Implementing compliance standards is one thing. Ensuring they're followed on a routine basis is quite another. With the help of an electronic health records consultant, establish regular risk assessments. This enables an ongoing process of ensuring that up-to-date processes and procedures are in place, potentially pinpointing areas of risk long before they become costly mistakes. Some key aspects every risk assessment should look for include:

• Data breaches

• Unauthorized access

• Security threats

Develop strategies to address and improve these areas as needed. At the same time, create and maintain audit logs that enable a straightforward way to verify access to patient files and documentation. Engage in action when there is any indication of unauthorized or suspicious activity.

Conduct Online Compliance Monitoring and Review

Updating your team, conducting audits, and ensuring your current systems are secure is the first step and should be continued throughout the practice on a routine basis. There are various ways to streamline this process:

• Utilize routine training programs with the EHR consultant to ensure the practice is up-to-date with all program updates specific to compliance concerns.

• Collaborate with vendors to improve safety measures and address compliance-related challenges.

• Support staff through re-training, as needed, and provide supportive guidelines. If there are ongoing concerns, address them effectively through proactive engagement.

Turn to a Team to Help You

Electronic record system management and compliance are so critical that it's essential to get the right help to support your organization. Turn to TempDev for the hands-on support you need through an electronic health records consultant.