any express restriction on permissible media for creating and storing medical records.21 Medical records may be authenticated by signature, written initials, or computer entry.22 Thus, the conditions of a hospital's participation in the Medicare program pose no barrier to the use of computer-based patient records.

The Medicare conditions of participation for long-term care facilities do not expressly restrict the media for creation and storage of the records.23 However, they require each individual who completes a portion of the assessment to "sign" the assessment.24 In addition, these conditions of participation require that, at each visit to a resident, the physician supervising the resident's medical care must "write, sign and date progress notes" and "sign all orders." 25 It is not clear whether these conditions of participation permit a fully automated record because it is not clear whether authentication by computer code or key provides the required signature and whether a progress note made on a computer fulfills the requirement that a physician must write the note.26

The Health Care Financing Administration (HCFA) permits physician certifications of medical necessity to be executed by computer or transmitted to a hospital by facsimile machines. A provider seeking permission for its physicians to attest to medical necessity on a computer or by facsimile must be able to demonstrate to its intermediary that its system contains adequate safeguards of accuracy and confidentiality and meets certain other standards.27


42 C.F.R. §482.24.


C.F.R. §482.24(c)(1)(ii).


42 C.F.R. §483.75(n).


42 C.F.R. §483.20(c)(2).


42 C.F.R. §483.40(b).


Apparently, the Health Care Financing Administration (HCFA) believes that these conditions of participation would permit a fully automated record because HCFA is discussing with nursing home operators the possibility of requiring that nursing homes computerize resident assessment records to comply with the provision of the Omnibus Budget Reconciliation Act of 1987 requiring maintenance of a uniform, minimum data set on residents' conditions. See Paula Eubanks, "Homes Doubt They Can Computerize per HCFA's Request," Hospitals 64, no. 23 (1990):56.


See the HCFA Medicare Hospital Manual Transmittal No. 567 (July 1989). The provider's request must explain (1) the provider's physician identification system, (2) system safeguards to ensure confidentiality, (3) how data are displayed for physician review before electronic attestation, (4) how physician identity is determined upon certification and stored in the provider's system, (5) how the system records a system-generated date and time of entry at the point of attestation, (6) system backup procedures for prolonged downtime, and (7) how the physician verifies that attestations executed through the system have been correctly recorded. HCFA permits use of physician access systems that employ an alphanumeric identifier or biometric identification of physicians.

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