CPSO Introduces Changes to Records Management Policy

By: Sari Feferman

The College of Physician’s and Surgeon’s (CPSO) Medical Records Management Policy (the “Policy”) was recently expanded. These updates were largely in response to the number of complaints the CPSO receives related to record ownership when a physician leaves a practice and general confusion regarding the ownership of medical records.

The Policy requires physicians to have a written agreement that sets out the custodian of medical records and clear accountabilities regarding medical records. The Policy requires that the written agreement be in place prior to establishing a group practice, business arrangement, or employment relationship. If physicians do not have written agreements that address custodianship, according to the Policy, they must establish the written agreement as soon as possible after starting the practice.

The Policy also sets out the requirements for the written agreements, such as the custody and control of medical records under any circumstance (including termination of employment or changes in the practice arrangement). In addition, the Policy addresses the storage, retention and destruction of medical records and how patients should be able to access and transfer their medical records.

The expansion of the Policy is a response to medical practices having moved away from sole practitioner arrangements towards group practice models and an increase in the use of a shared EMR system, where one physician owns the EMR license. Conflicts between physicians and clinic owners who own the EMR system continue to arise. These issues are addressed in the Policy’s requirement for written agreements which will reduce future conflicts regarding medical record ownership and clarify the rights and responsibilities of health information custodians and patients.

To complement the Policy, the CPSO provides physicians with Advice to the Profession (the “Advice”) with respect to medical records management. The Advice accompanies the Policy and provides additional information regarding the Policy, including:

  1. the circumstances when physicians are the custodians of their patients’ medical records;
  2. what to do if the custodian of the medical records is not acting in accordance with the Policy or the legislation;
  3. what to consider when transitioning to an EMR system (or from one EMR system to another); and
  4. how to determine which EMR systems are compliant with the Personal Health Information Protection Act, 2004.

Generally this new Policy is a positive development for physicians. The Policy and Advice provide regulatory guidance that is more in accordance with how most physicians practice (i.e., in a group setting), and provide more clarity on the obligations that will apply in the circumstances of the dissolution of these group practice settings.

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