A Research Of Legal Issues Relevant To Electronic Health Record In China

As the construction of China's medical informationization continues to increase, the electronic health record has already been widely used in medical institutions. Compared with the traditional paper medical record, the electronic health record (Electronic Health Record, EHR) is a medical record making use of the information technology and the networking technology. The promotion of electronic health record standardizes the medical behavior of medical staff, reduces the work intensity of doctor, improves the medical level, reduces the management cost of hospital, and achieves the information sharing of medical system.At present, the advancement of high-level electronic health record meets very big resistance in China. There are two aspects for medical institutions to suit the development of electronic health record: firstly, records conforming to the laws and regulations should be provided when the medical dispute happens; Secondly, the fund and the talented person should be put into the construction of system of electronic health record. The electronic health record must guarantee the validity, the security and the Non-repudiation of medical information for a smoother promotion of the electronic health record, better acception of both the hospital and patients, and a more healthy and effective construction of informationization of the hospitalOn April 1, 2005, the implementation of"the Electronic Signature Law of the People's Republic of China"(hereafter refers to as"Electronic Signature Law") established a legal effect of the electronic signatures, swept the obstacles of electronic medical record or being a legal evidence. At present, the most urgent thing of informationization of development system in China is to consummate the laws and regulations of electronic health record, such as evidence potency, the right of privacy of electronic health record and the management of electronic health record, etc. The research on the legal issues relevant to electronic health record is done on the basis of the survey of questionnaires on 22 hospitals in Chongqing, Yongchuan and Wanzhou. There will be 6 chapters to analyze the matters from the legal aspect:The first chapter outlines the electronic health records, and carries on a summary of the concept, the type, the scope and the superiority of medical record and the electronic health record.The second chapter aims at the investigation and analysis on the application of electronic medical record in Chongqing. The investigation is carried on by the questionnaires of the application situations of electronic health record in 22 hospital, and its content includes five aspects: (1)the implementation and application of safety work of electronic health record; (2) the support and standard of government; (3) the behavior which most needs to be standardized in carrying out electronic health record; (4) the condition of the electronic health record's application; (5) the chief obstacle of the electronic health record's application. There are three reasons of bad application of electronic medical record through investigation and analysis (1) lack of unified professional standard for electronic health record; (2)effect of legal evidence of electronic health record; (3) deficient security and secrecy of the application of electronic health record.The third chapter is mainly the introduction of the legal research on electronic medical record in other districts and foreign countries, such as American, Japanese, Singapore, the Chinese Taiwan area, etc. Two enlightenments are got: (1) the establishment of the unified standard for electronic health record's data; (2) the proposal of the effective administrative standard for electronic health record.The fourth chapter is a research on the evidence potency of electronic medical record in China, on the basis of the explanation of four aspects: the present legislative situation of electronic health record in China, the legal issues of electronic signatures in the electronic health record, the legal characterization of electronic health record's evidence, the credibility of electronic health record.The fifth chapter is a research on the right of privacy of electronic health record in China. The solutions of preventing the leakage of patients'privacy are brought forward from the concept of patient's privacy and the patient's right and the phenomenon of the violation of patient's right of privacy in the application of electronic health record.The sixth chapter is a research on the standardized management of electronic medical record in China. The present problems are discoverd from input, revision and preservation of electronic health record, and then the proposal of standardizing the management of electronic health record is put forward.