Clinical Data Management - EGEN.02
The identity of a patient presenting for service must be confirmed through the Client Registry prior to any other interactions with the patient's health information exchange system data.
To assist in making your medical treatment decisions and treatment plans, the software application will automatically store data received from the HIE system. You may also make adhoc requests for more recent data from an HIE system than what is currently stored in your application.
Your application will clearly identify the source (e.g., EHR or EMR) of patient data you are viewing so you can differentiate between the data you requested from an HIE system from data entered locally or received from another source (e.g., lab data from Excelleris). When reviewing the stored data, the most current version will always be displayed to you; however, you will be able to view previous versions of the data stored in the application.
With the data provided, you will be be able to recreate a view of the data that comprised the patient record at a point in time, allowing you to review what you did on a certain day/time. Although you won't be able to modify the stored HIE data, annotations are permitted.
Masking Data Stored in the EMR
A patient may request you to mask all or a portion of their stored data - you can perform this request by masking the data at either the chart level or the specific data level. This could be data received from the HIE, data you received from other sources, or entries you have made. If you do mask a patient's data, it will not be masked to you but all other users in your clinic will have to provide a reason to view the masked data.
Unmasking Data Stored in the EMR
You will be alerted when you access a patient chart containing masked data. If you did not mask the data yourself, you will have to provide a reason to view the data. Once you exit the patient chart or your session expires, the information will automatically remask. These activities will be tracked in your application's audit log
Each HIE system (e.g., PharmaNet, Provincial Laboratory Information Solution) has specific rules for protection and display of the data protected by a patient keyword. These rules are described in the Conformance Standards and the education materials related to the HIE system being used.