Q&A: Electronic medical records versus print copies

Q: If an individual requests an electronic copy of protected health information (PHI) and the covered entity (CE) maintains that particular record only on paper, what is the standard procedure? Can a paper copy suffice? Does the covered entity need to find a way to deliver the record electronically?

A: A CE is not required to purchase a scanner to create electronic copies of paper records, but if the CE can readily produce an electronic copy of PHI by scanning paper records, it must do so.

If the individual requests an electronic copy of PHI in a specific format, and a CE maintains that PHI only on paper, the CE must provide the individual with the electronic copy, in the format requested, if the copy is readily producible in that format.

If the copy is readily producible electronically but not in the specific format requested, the CE may offer the individual the copy in an alternative readable electronic format.

If the copy is not readily producible in electronic form, or the individual declines to accept the electronic format(s) that are readily producible by the CE, then the CE may provide the individual with a readable hard copy of the PHI to satisfy the access request.

For example, a CE that maintains the requested PHI only on paper may be able to readily produce a scanned PDF version of the PHI but not the requested Word® version. In this case, the CE may provide the individual with the PDF version if the individual agrees to accept it. If the individual declines to accept the PDF version, or if the covered entity is not able to readily produce a PDF or other electronic version of the PHI, the covered entity may provide the individual with a hard copy, such as a photocopy, of the PHI.

Editor's note: Mary D. Brandt, MBA, RHIA, CHE, CHPS is a healthcare consultant specializing in healthcare regulatory compliance and operations improvement. She is also an advisory board member for BOH.