Traditionally, the patient medical record was owned by the physician who created the record. However, electronic medical record systems—which might be shared among many health care providers in a clinic—have made it less clear who owns and controls the medical record.
In a multi-physician practice setting, physicians should (and in some cases, must) document their agreement on issues of ownership, custody of, and access to medical records by way of a data sharing agreement. Failure to do so may be considered professional misconduct by the College.
The College’s medical records standard stipulates that “[i]n all situations where a physician is creating medical records in a group or shared medical record environment, a data-sharing agreement should be in place which addresses how issues of ownership, custody and enduring access by individual physicians and patients will be addressed, including following relocation, retirement or death of the physicians.” In cases where a physician is not the owner of the EMR licence or the clinic, the College mandates that a formal contract be entered into between the physician and the clinic/EMR vendor addressing issues of custody, confidentiality, and enduring access.
The Practice or clinic should consider implementing a “Responsible Physician Policy” to assist physicians with clarifying their rights and responsibilities, both with respect to medical records and patient care.
The Walk-In, Urgent Care and Multi-Physician Clinics Standard of the College of Physicians and Surgeons of BC establishes requirements for the medical administration of a clinic. It makes every physician working in the clinic responsible for ensuring that systems are in place to provide appropriate continuity and follow-up care.
In circumstances where a patient may be cared for by more than one physician or allied health care provider, each provider is generally responsible for the care that they provide within their scope of practice. Medico-legal risk can result when the division and scope of responsibilities are not clearly established in policy. Hospitals often deal with this issue by having policies that set out the responsibilities of the “most responsible physician.”
The concept of “most responsible physician” can be adapted to clinics and group practices to assist physicians in clarifying their rights and responsibilities with respect to both medical records and patient care. When a Responsible Physician Policy is adopted, the rights and obligations of the parties can also be more easily documented in the data sharing agreement referred to above.
Appendix C contains a sample Responsible Physician Policy and Appendix D contains sample contractual terms relating to the rights and responsibilities of the most responsible physician.