New at EMR -Still scanning Documents -Is it needed with Drs. original signature?

[CHRISTY]

Hi everyone my name is Christy. I work at a Drs. office and we recently went electronic "we have IMEDICA." Anyway let me explain a little about how we are doing things. Here's an example, When we have a lab result it is printed and sent to the Nurses ELECTRONICALLY to the Message Board for Review, from there if it needs Drs. attention The PAPER RESULT IS SENT TO HIM for review - Dr Writes on the Report ANY CHANGES Needed or Follow up actions from this result. THEN we usually SCAN THIS PAPER DOCUMENT INTO IMEDICA BECAUSE IT HAS HIS LEGAL SIGNATURE ON IT. Is it LEGAL for The NURSES to TYPE HIS COMMENTS INTO THE NOTE FIELD that is attached to the result document? OR MUST WE SCAN EACH PAPER, IF ANYONE KNOWS THIS PLEASE LET ME KNOW. I WOULD LIKE TO send it Electronically to the DR on His message board "IN IMEDICA" It shows up as "STAT LAB RESULTS for review" Our Dr. can CLICK ON THIS FOR REVIEW and Type in The Note box That is attached to this document any remarks necessary to follow up on this lab. " Example Patient to have Potassium cheked in 2 weeks. THEN SIGN HIS NAME ELECTRONICALLY. IF WE KNOW THIS IS LEGAL. - SO PLEASE IF ANYONE KNOWS IF WE HAVE TO SCAN THE DRS. ORIGINAL SIGNED PAPER PLEASE LET ME KNOW. THANKS, CHRISTY

[techguy]

Christy,
We know that painful process all to well. You have to hate scanning just for the legal signature.

We solved it by creating an HL7 interface between our EMR software and our lab software (we have an in house lab, but this also works with Quest or other reference labs). When the lab is ordered it gets sent to the lab. When the lab is resulted the results are sent to our EMR. The doctor is notified that results are there and need to be read. We read them through a simple check box. However, the key is that the doctor is logged into the EMR using their unique login and password. Therefore, the EMR uses that login to apply the doctor's signature. We'd like for the doctor to be able to put a follow up note on the lab when they are signing it, but that feature hasn't been created yet in our EMR. Instead the doctor just creates a simple note in the patients chart with what was done or what needs to be done.

I should mention that 1. I'm not a lawyer and can't give legal advice and 2. digital signature laws may vary by state. I'm in Nevada and our lawyer essentially said that if we used a unique login that can be traced to 1 specific user, then it works fine as a digital signature. I should just mention that this is why having proper password policies is so important. Otherwise, a digital signature doesn't mean much. Unfortunately, you'll have to consult a lawyer to find out about digital signatures in your area.