Informed Consent in Electronic Medical Record Systems

Abstract

Informed consents, either for treatment or use/disclosure, that protect the privacy of patient information subject to law that in certain circumstances may override patient wishes, are mandatory practice in healthcare. Although the healthcare industry has widely adopted Electronic Medical Record (EMR) systems, consents are still obtained and stored primarily on paper or scanned electronic documents. Integrating a consent management system into an EMR system involves various implementation challenges. The authors show how consents can be electronically obtained and enforced using a system that combines medical workflows and ontologically motivated rule enforcement. Finally, the authors describe an implementation that uses open-source software based addition of these components to an open-source EMR system, so that existing systems needn't be scrapped or otherwise rendered obsolete.