HHS and CMS support the use of electronic health records (EHR), and their goal is that by 2014 most Americans will have access to health care providers who use EHRs. The benefits of EHRs include better patient care, and reduced costs to providers, Medicare and Medicaid. Presently, providers are permitted to use any system of medical records that best suit their needs, including paper and/or electronic systems.
State survey agencies are responsible for enforcing various conditions of participation (CoPs), conditions for coverage, or conditions for certification (CfCs). Toward that end, providers must grant access to any medical record when requested by a surveyor. Surveyors must establish with the facility the process they will follow to have unrestricted access to the medical records. If a surveyor requests access to an EHR, the facility must, among other things, provide the surveyor with a tutorial on how to use its particular electronic system, and designate an individual who will, upon request, assist the surveyor in accessing the electronic information. The facility must also be able to provide a paper copy of any record, regardless of whether the records are stored in paper or electronic form. In turn, surveyors should make reasonable efforts to avoid the printing of entire records, and should request paper copies of only those records that are necessary to verify noncompliance, unless protocols require otherwise. Refusing access to any medical record is a basis for terminating the facility's Medicare agreement.
While providers are required to maintain the content and confidentiality of the medical records, surveyors are not expected to review whether the facility has fulfilled its obligations under the Health Insurance Portability and Accountability Act. Rather, they should review how the EHR system is being used, and whether that use is consistent with the Medicare CoPs or CfCs.
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