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Ensuring Records Accessible for Regulatory Processes

Someone in scrubs using a tablet

A new provision to the Medical Records Management policy clarifies physicians’ obligation to ensure their records are accessible to CPSO, when required.

The provision, approved by Council at its June meeting, specifies that physicians only engage with EMR service providers who are willing and able to make medical records accessible, where required, as part of the College’s regulatory processes, and to ensure EMR service providers are aware of these obligations.

The General Regulation under the Medicine Act, 1991 requires physicians make their medical records available for statutory or regulatory inspection, and the Medical Records Management policy sets out multiple expectations in relation to physicians’ obligation to ensure access to their records, even when the records are stored with a third party.

The amendments build on existing obligations set out in policy that require physicians exercise due diligence in the selection of an EMR system and/or EMR service provider.

“Notwithstanding existing legal obligations and policy provisions, we believed that the opportunity existed to provide additional clarity and specificity regarding physicians’ obligations when engaging with EMR service providers,” said Dr. Craig Roxborough (PhD), the director of CPSO’s Policy Department.

The policy’s Advice document helps further clarify that when engaging with commercial services offering EMR services, these providers are acting on behalf of physicians and physicians need to ensure their obligations can be met.

To ensure commercial service providers are aware of their obligations with respect to medical records, it is generally good practice to: 

  • Make any agreements with such providers in writing;
  • Ensure agreements reflect the same legal and regulatory requirements that apply to physicians who have custody or control of records; and/or
  • Seek legal counsel or contact the CMPA for advice in these circumstances.