SCHEDULE "C" ELECTRONIC MEDICAL RECORD INFORMATION EXCHANGE PROTOCOL - PDF

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SCHEDULE C to the MEMORANDUM OF UNDERSTANDING AMONG ALBERTA HEALTH SERVICES, PARTICIPATING OTHER CUSTODIAN(S) AND THE ALBERTA MEDICAL ASSOCIATION (CMA ALBERTA DIVISION) ELECTRONIC MEDICAL RECORD INFORMATION
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SCHEDULE C to the MEMORANDUM OF UNDERSTANDING AMONG ALBERTA HEALTH SERVICES, PARTICIPATING OTHER CUSTODIAN(S) AND THE ALBERTA MEDICAL ASSOCIATION (CMA ALBERTA DIVISION) ELECTRONIC MEDICAL RECORD INFORMATION EXCHANGE PROTOCOL (AHS, PARTICIPATING OTHER CUSTODIAN(S) AND PARTICIPATING PHYSICIANS USING AN AHS EMR SYSTEM) A DOCUMENT CONCERNING THE ACCESS TO, USE AND DISCLOSURE OF INFORMATION IN THE ELECTRONIC MEDICAL RECORD EMR IEP Jan version as amended from time to time) A.1 Purpose of This Document This document, the Electronic Medical Record Information Exchange Protocol (the Protocol ), establishes the specific rules for the access to, use, disclosure and protection of EMR Information contributed to and stored in an EMR System 1 that is owned and operated by AHS (in this Protocol, the EMR System ) including: EMR Information from Participating Physicians, Participating Other Custodian(s) and Alberta Health Services; EMR Information that is accessed by EMR Custodians in the EMR System; and, EMR Information that is used for Secondary Use and Disclosure purposes. These rules bind all EMR Custodians and EMR Affiliates utilizing the EMR System. Custodians who choose not to sign the Information Sharing Agreement (the ISA ) as amended from time to time, or other appropriate legal agreements may not access, use or disclose EMR Information in the EMR System. 1 1 The phrase located in an AHS facility was removed by Governance Committee motion on November 21, A.2 Why Rules Are Required The Health Information Act establishes the legal authority and limits for the exchange of health information. It makes each Custodian in the health system responsible for the collection, use and disclosure of health information. However, the Health Information Act recognizes that a wide variety of circumstances exist in the delivery of care. While the Health Information Act establishes general rules, it provides Custodians considerable latitude within those rules for discharging their responsibilities. An EMR is an electronic record of an individual's health information. An EMR typically records a history of clinical encounters maintained by Physicians and other health care providers in an electronic information system. Since health information is shared electronically in the EMR System by a large number of Physicians and other health services providers, it is necessary to establish clear and consistent rules for Custodians. The rules set forth in this Protocol define the expected use of EMR Information by EMR Custodians, thereby providing consistency within the larger context of Custodian activity and their obligations under the Health Information Act. Only those rules that are unique to the EMR context are contained within this Protocol. Rules for how information may be collected, used and disclosed in the context of the Alberta EHR may be found in the Alberta Netcare Information Exchange Protocol. EMR IEP Jan version as amended from time to time 2 A.3 History of This Document This Protocol was created and first released under Version 1.0, February A.4 Revisions to This Document This Protocol may be revised from time to time by the Governance Committee with input from the EHRDSC as required. All revisions to this Protocol will be made available to EMR Custodians 30 days prior to the effective date of the revisions. By continuing to access EMR Information in the EMR System following the effective date, an EMR Custodian accepts and agrees to comply with the revisions. The Governance Committee may, at its ongoing meetings, make relatively minor revisions to this Protocol that do not materially affect the continued use of the EMR System. Rather than release continual revisions to the Protocol, these minor revisions will be consolidated and published in periodic updated releases. When published, these updated releases will become effective in the same manner as major revisions. They will be made available to EMR Custodians 30 days prior to the effective date of the revisions. By continuing to access the EMR System following the effective date, an EMR Custodian accepts and agrees to comply with the revisions. A.5 Guiding Legislation The rules outlined in this Protocol have been developed in consideration of the Health Information Act (and other applicable legislation) and serve as a vehicle for the clarification and the operational application of selected sections of that legislation, particularly as it relates to health information in the EMR System. Definitions of terms used in the Health Information Act also apply to those terms when used in this Protocol. A.6 Guiding Principles In its adoption and continuation of this Protocol, the Governance Committee will strive to maintain alignment with the following principles: Protocol rules will recognize and align with legislated and EMR Custodians ethical obligations. Protocol rules will be structured to assure the privacy and security of an individual s health information without placing onerous restrictions and processes on those who have a legitimate need to access and use information from the EMR System. The Protocol will not be a reiteration of the Health Information Act, but rather a document to highlight and clarify important aspects of the Health Information Act as it relates to the use and disclosure of health information in an EMR System. The Protocol will further elaborate on the use and disclosure of health information from the EMR System where the Act does not provide sufficient guidance. EMR IEP Jan version as amended from time to time 3 Protocol rules will articulate EMR Custodian obligations but not necessarily the means by which EMR Custodians are to meet those obligations. In that regard, EMR Custodians should use their professional judgement or other guidelines that may be released from time to time by the Governance Committee. Information Exchange Protocol rules will articulate EMR Custodian obligations but will not provide guidance in matters where discretion may be exercised. Such guidance is expected to be provided through the CPSA and other applicable health professional bodies. A.7 Limitations of This Document This Protocol does not define the scope or necessarily represent the current architecture of the EMR System. In some cases, these rules may infer functionality which exceeds that of the EMR Systems. This approach has been taken to assist EMR Custodians in understanding the possible impacts of future functionality, and to recognize that the EMR System will continue to be an evolving tool for the use of health services providers in their delivery of health services to Alberta residents. A.8 Contact Information Questions regarding this Protocol or requests to contact the Governance Committee can be directed to the Information Stewardship Office ( ISO ) at EMR IEP Jan version as amended from time to time 4 IEP Jan (as amended from time to time 5 instructions of a Patient to his/her Physician, including individual data element masking or global person masking. Memorandum of Understanding Participating Other Custodian Participating Physician Primary use Secondary use Security Unmasking An agreement entered into between AHS and the AMA dated effective the 1st day of April, 2012, as amended from time to time, together with consequential amendments resulting from adding Participating Other Custodian(s)to the Memorandum of Understanding, establishing the Information Sharing Framework, and the Governance Committee. A Participating Other Custodian is a Custodian, other than AHS and Participating Physicians, that is authorized by AHS to use an EMR System within its facilities or otherwise, including through authorized network access, for use by that Participating Other Custodian and its affiliates; A Physician that signs a Participating Physician Agreement signifying his/her acknowledgement of the Memorandum of Understanding, and agreement with the terms of the ISF, including the ISA, IMA and this Protocol. The use of EMR Information for the purpose of providing Health Services to Patients and includes the reproduction of that information, but not the Disclosure of that information The use of EMR information by a Party for any purpose not directly related to the provision of Health Services to the Patient whom is the subject of that information including, without limitation, the provision of Health Services to Patient populations or to advance Patient safety, or health system management. The process of protecting EMR Information by assessing threats and risks to that EMR Information and implementing the procedures and systems to restrict access and maintain the integrity of that EMR Information. The temporary removal of Masking from EMR Information during a session of access to an Individual s EMR Information by an EMR Custodian. B.2 Glossary of Terms Used in This Document and Defined in the Health Information Act IEP Jan (as amended from time to time 6 Affiliate Audit Collect In relation to a custodian, means (i) an individual employed by the custodian; (ii) a person who performs a service for the custodian as an appointee, volunteer or student or under a contract or agency relationship with the custodian; (iii) a health services participating custodian who has the right to admit and treat patients at a hospital as defined in the Hospitals Act; (iv) an information manager as defined in section 66(1); (v) a person who is designated under the regulations to be an affiliate; but does not include (vi) an agent as defined in the Health Insurance Premiums Act; or, (vii) a health information repository other than a health information repository that is designated in the regulations as an affiliate. A financial, clinical or other formal or systematic examination or review of a program, portion of a program or activity. To gather, acquire, receive or obtain health information. Custodian Means (i) (ii) (iii) (iv) (v) the board of an approved hospital as defined in the Hospitals Act other than an approved hospital that is (A) owned and operated by a regional health authority established under the Regional Health Authorities Act, the operator of a nursing home as defined in the Nursing Homes Act other than a nursing home that is owned and operated by a regional health authority established under the Regional Health Authorities Act; an ambulance operator as defined in the Emergency Health Services Act; a provincial health board established pursuant to regulations made under section 17(1)(a) of the Regional Health Authorities Act; a regional health authority established under the Regional IEP Jan (as amended from time to time 7 (vi) Health Authorities Act; a community health council as defined in the Regional Health Authorities Act; (vii) a subsidiary health corporation as defined in the Regional Health Authorities Act; (viii) a board, council, committee, commission, panel or agency that is created by a custodian referred to in sub-clauses (i) to (vii), if all or a majority of its members are appointed by, or on behalf of, that custodian, but does not include a committee that has as its primary purpose the carrying out of quality assurance activities within the meaning of section 9 of the Alberta Evidence Act; (ix) (x) (xi) a health services provider who is designated in the regulations as a custodian, or who is within a class of health services providers that is designated in the regulations for the purpose of this sub-clause; a licensed pharmacy as defined in the Pharmacy and Drug Act; the Department; (xii) the Minister; (xiii) an individual or board, council, committee, commission, panel, agency or corporation designated in the regulations as a custodian; but does not include (xiv) a Community Board or a Facility Board, as those terms are defined in the Persons with Developmental Disabilities Community Governance Act other than a Community Board that is designated in the regulations as a custodian. Department Health information Health professional body Health service The Department administered by the Minister. One or both of the following: (i) (ii) diagnostic, treatment and care information; registration information. A body that regulates the members of a health profession or health discipline pursuant to an Act. A service that is provided to an individual for any of the following IEP Jan (as amended from time to time 8 purposes: (i) (ii) (iii) (iv) (v) protecting, promoting or maintaining physical and mental health; preventing illness; diagnosing and treating illness; rehabilitation; caring for the health needs of the ill, disabled, injured or dying, but does not include a service excluded by the regulations. Health services provider Individually identifying Minister Non-identifying Record Research Research ethics board Use An individual who provides health services. When used to describe health information, means that the identity of the individual who is the subject of the information can be readily ascertained from the information. The Minister determined under section 16 of the Government Organization Act as the Minister responsible for this Act. When used to describe health information, means that the identity of the individual who is the subject of the information cannot be readily ascertained from the information. A record of health information in any form and includes notes, images, audiovisual recordings, x-rays, books, documents, maps, drawings, photographs, letters, vouchers and papers and any other information that is written, photographed, recorded or stored in any manner, but does not include software or any mechanism that produces records. Academic, applied or scientific health related research that necessitates the use of individually identifying health information. A body designated by the regulations as a research ethics board. To apply health information for a purpose and includes reproducing the information, but does not include disclosing the information. IEP Jan (as amended from time to time 9 responsible to liaise with the EHRDSC for the purpose of ensuring The Governance Committee, or its representative, shall be Committee Information that is in the EMR System. Protocol pertaining to the access to, use and disclosure of EMR Governance The Governance Committee establishes and amends rules in this Topic 1.2 Operation of the Information Exchange Protocol obligations under the Health Information Act. responsibility of each EMR Custodian to meet his/her or its compliance with the Health Information Act. It is the Full compliance with this Protocol does not necessarily assure full Information Act the Health Act. Deference to These rules neither replace nor supersede the Health Information Act. Information Health the of 32(2) and 32(1) sections under regulated is but Protocol this under covered not is System EMR an in information non-identifying of use and to Access Protocol Information. EMR identifying individually of Application of disclosure and use and, to access the to only applies Protocol This EMR the System Information in EMR Protocol. this of conditions and terms the to subject and access use is System EMR the in Information EMR all of use and to Access to Authority Protocol , February on Committee of Currency this Steering the by approved was Protocol this of 0.3 Version Protocol the of Authority 1.1 Topic IEP Jan (as amended from time to time 10 continued consistency in their approach to health information sharing. Coming into effect EMR Custodian joint responsibility for accuracy and confidentiality of Health Information Physicians as EMR Custodians Alberta Health Services as an EMR Custodian Participating Other Custodian(s) as an EMR Custodian Rules pertaining to the access to and, use and disclosure of EMR Information in the EMR System are documented in this Protocol and come into effect according to the terms of the Information Sharing Agreement In a shared EMR environment, it is recognized that there are multiple health service providers that add or modify Patient Health Information, each sharing responsibility for the accuracy and confidentiality of that information. Each EMR Custodian must make reasonable efforts to ensure that the Health Information that is under that EMR Custodian's custody or control is accurate, complete and that the confidentiality of that Health Information is maintained Any Physician who has signed the Physician Participation Agreement is considered to be an EMR Custodian. In his/her role as an EMR Custodian, a Participating Physician may only use and disclose EMR Information for authorized purposes in accordance with this Protocol and the Health Information Act Alberta Health Services is an EMR Custodian. In its role as an EMR Custodian (compared to its role as Information Manager for the EMR System), Alberta Health Services may only use and disclose EMR Information for authorized purposes as per this Protocol and the Health Information Act Each Participating Other Custodian is an EMR Custodian. In its role as an EMR Custodian, a Participating Other Custodian may only use and disclose EMR Information for authorized purposes as per this Protocol and the Health Information Act. Alberta Health Services as Information Manager for EMR Systems Notwithstanding its role as an EMR Custodian, Alberta Health Services is the Information Manager of the EMR System. In its role as the Information Manager of the EMR System, Alberta Health Services is limited to only using and disclosing EMR Information in its capacity of an Information Manager as authorized by the Information Management Agreement and the Health Information Act. IEP Jan (as amended from time to time 11 Role of the Information Manager The Information Manager, in accordance with the Information Sharing Agreement and the Health Information Act, will, in addition to other obligations set forth in the Health Information Act and the Information Management Agreement: a. process, store, retrieve or dispose of EMR Information in the EMR System as required; b. provide information management services for the EMR System, as required; c. monitor and audit EMR Information in the EMR System on a continuing basis; and, d. where required, report to the ISO Should the role of Information Manager for the EMR System be transferred from Alberta Health Services to another organization, this Protocol will continue to guide the operation of sharing of EMR Information in the EMR System. General authority to access EMR Information General responsibilities of EMR Custodians Any EMR Custodian requiring access to EMR Information in the EMR System may use the EMR Information in respect of which access has been granted, that is stored in the EMR System, where such access: a. has been granted to the EMR Custodian pursuant to the Information Sharing Agreement; b. is consistent with the authorization for access established in this Protocol and the Health Information Act; and, c. will be made through a unique system account and profile assigned to that EMR Custodian Each EMR Custodian has a duty pursuant to Section 60 of the Health Information Act to protect the confidentiality of EMR Information in the EMR System and to protect against any reasonably anticipated threat or hazard to the security of that EMR Information, or unauthorized use, disclosure, modification or unauthorized access to the EMR Information EMR Custodians are responsible for all EMR information accessed and used by the EMR Custodian and their EMR Affiliates in the EMR System or while such EMR Information falls under the authority of this Protocol. General responsibilities of EMR Any EMR Affiliate of an EMR Custodian who requires access to the EMR System for the purpose of either providing EMR Information to or receiving EMR Information from the EMR IEP Jan (as amended from time to time 12 Affiliates System must be authorized by an EMR Custodian for such access EMR Affiliates will retain full responsibility for all EMR Information they access from
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