Medical Records and the Law

66 CHAPTER 4: MEDICAL RECORDS ENTRIESEHR.The only other alternative for the institution or state hospital associationis to embark on the often long and difficult task of obtainingan amendment of the applicable restrictive state law.Auto-AuthenticationThe introduction of computer technology to health information managementhas provided opportunities to improve the speed and accuracyof the authentication process. Computerizing medical records,however, has introduced a new risk that the technology will replacerather than supplement the role of practitioners and hospital personnelin this process of verifying the accuracy and completeness of medicalrecords. In particular, these concerns have arisen with respect tothe process of auto-authentication, in which a physician authenticatesa report by computer code before the report is transcribed. Physiciansenter an electronic signature, and agree to review and correct transcriptsof EHR within a certain time frame. If no corrections are madeby the deadline, the record is deemed complete. Although both federaland state authorities allow electronic signatures to replace handwrittenones, they also require that authentication, regardless of theformat, attest to the accuracy of the record. 46 To the degree that anauto-authentication system does not allow a physician to make thisverification, many regulatory agencies have adopted the position thatthe authentication requirement is not fulfilled.Auto-authentication systems frequently contain safeguards thatprotect some of the essential functions of the authentication process,however. For example, some facilities require physicians to sign an attestationthat they will review all records and, unless they request corrections,the medical records department may enter the physician’ssignature. These attestations may include a provision in which thephysician agrees not to dispute the accuracy of any record based on theabsence of the physician’s signature on any document. Such an agreementprovides no supporting evidence that a physician actually reviewedthe record, however, and therefore does not resolve concernsregarding the accuracy of the record’s contents.46See M.Kadzielski and M. Reynolds, “Legal Review: Auto-authentication of MedicalRecords Raises Verification Concerns,” Topics in Health Information Management 14 (1):77–82 (1993).