Same value as paper records

According to the Circular, all electronic medical records that have been created, updated, displayed, digitally signed and stored on electronic devices that meet the requirements detailed in the Circular will have the same legal value as their paper counterparts stipulated in Article 59 of the Law on Medical Examination and Treatment.

Electronic medical records include inpatient and outpatient case histories and other medical dossiers as per regulations of the Ministry of Health.

Electronic medical records must contain all information and fields as seen in medical records currently in use at healthcare facilities per existing regulations on the medical dossiers’ forms and other regulations related to the payment of health examination and treatment expenses.

Each patient will be provided with a number and have their electronic medical record stored at a healthcare facility. This record contains all patient information available on the paper medical records, and it must have the digital signature of the person responsible for filling in or updating the information in the medical records.

Healthcare facilities must guarantee the privacy of the personal information as stated in the online information security law and update the records no later than 12 hours after patients have health checks or are hospitalised.

In cases where the check-up or treatment lasts longer than 12 hours or when an IT incident occurs, the information on the records must be updated within 24 hours.

Regarding insurance-covered health examinations and treatment, the Department of Health Insurance under the Ministry of Health will co-ordinate with relevant agencies and organisations to develop data output criteria to be utilised in the management, auditing and payment of health examination and treatment expenses covered by health insurance.

Storing electronic medical records

Healthcare facilities are allowed to store electronic medical records in place of paper medical records when they meet the following requirements: the electronic medical records’ management software reaches a high level of competition as provided for in Circular No 54/2017/TT-BYT dated December 12, 2017 by the Ministry of Health on the set of criteria for information technology in healthcare facilities; the storage device must have enough capacity to preserve the electronic medical records within time periods set in Item 3, Article 59 of the Law on Medical Examination and Treatment; a backup of all electronic medical records must be kept at a data centre service provider which satisfies the requirements set out by the Ministry of Information Communications.

For healthcare facilities under the management of the Ministry of Defence, the backups of electronic medical records will be kept in line with the Ministry of Defence’s regulations.

In cases of mergers between healthcare facilities, the electronic medical records must be transferred to the new facility. In case a healthcare facility is dissolved, the electronic medical records must be handed over to the relevant authorities before dissolution.

Healthcare facilities are expected to perform backups of all electronic medical records they manage every week, as per Item 3, Article 59 of the Law on Medical Examination and Treatment.

Electronic medical record deadline

In Circular No 46/2018/TT-BYT, the Ministry of Health also set out a roadmap for the implementation of electronic medical records.

In the 2019-2023 period, all Grade 1 healthcare facilities and higher must upgrade their IT systems to implement electronic medical records as per the circular, while other healthcare facilities shall make appropriate preparations for the rollout in line with their own capacity and local demands and start to implement electronic records once the conditions stated in the circular are met.

In the 2024-2028 period, all healthcare facilities nationwide must implement electronic medical records. Those facilities under the management of the Ministry of Health or other ministries failing to comply must report to the Ministry of Health, and similarly, those facilities under the management of centrally-directed provinces and municipalities’ health departments must report to their respective local health departments.

The report must provide clear details on the reasons why electronic health records have not been implemented and a tentative roadmap on the implementation./.