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Use of signatures in healthcare

03/03/2022 by MaxMD

Healthcare organizations collect hundreds of signatures a day

As healthcare continues to move to a digital environment, many tasks once conducted in person are now accomplished virtually.  This includes signing documents.  Signed documents are used by hospitals of all sizes, ambulatory facilities, remote and mobile staff, mental healthcare providers and healthcare organizations carrying out clinical trials. Typical documents using signatures include:

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While it is has become much easier to “sign” a document electronically, the real question is does that signature carry the same weight as a handwritten one?  When signatures aren’t provided in person, how do you know who actually signed the document? How do you ensure details of the original document are not changed after it is signed?  Understanding the answers to these questions will ensure that you make the right decision for your organization, your coworkers, yourself, and the individuals you work with when signing important documents in a healthcare setting.


Concerns with electronic signatures in healthcare

When it comes to signing documents on-line,  all signatures are not the same.  It is important to understand the difference between an electronic signature and digital signature.  An electronic signature (also known as e-signature) conveys the act of signing anything created or captured by a computer or other electronic device. This can include using a touch screen with a stylus or finger to sign you name; attaching a picture to a document; or even typing in your name. Regardless of how you apply the e-signature, the act of signing does not prevent one individual from signing another person’s name and there is no security or verification to ensure the digital artifact that was signed remains unchanged after the e-signature is affixed.

Have you ever used a public computer to electronically sign a document? Or cropped and saved an image of your signature to add to a document?  These are a few examples of how electronic signatures are used.  Have you thought about how easy it is to sign a document that way and how easy it would be for someone else to do the same with an image of your signature?  The simplicity of applying an electronic signature contributes to  the vulnerabilities inherent in this signature method.   Electronic signatures make it easy to copy, tamper with, or even forge a signature. Subsequent to adding an e-signature to a document, there is nothing preventing another party from altering the material that was signed.

The American Bar Association describes major concerns that exist with blindly adding signatures to a document in their article, “Electronic Signatures: Not So Fast.” Their major concern revolves around how easy it is for the person(s) signing the electronic document to deny they actually signed the document.  This is where verifying the person’s identity, proving authenticity, and ensuring the document has not been tampered with become critical. Luckily, there is a better way to sign an electronic document, and this leads to the use and understanding of digital signatures. 


Use of Digital signatures in healthcare

Conversely, digital signatures provide trust that the signer is who they claim to be. They support the potential to authenticate the identity of the signer, thereby confirming that the signer is who he or she purports to be. Additionally, digital signatures make it possible to determine if a signed artifact has been altered after it was signed.  No one can change a period or a comma within the document without invalidating the digital signature. Only digital signatures offer this level of trust, authenticity, and assurance of protection. This method of on-line signing  makes detecting forgery, electronic manipulation of the content, while assuring accountability and non-repudiation for  signed artifacts.

Digital signatures include several characteristics  that distinguish them from basic electronic signatures. First, a digital signature is backed by a digital certificate which is issued after identity proofing the individual. The identity proofing process ensures the identity of the person associated with the certificate can be trusted.  Second, digital signatures ensure the authenticity of the document and its source because a “fingerprint” of the signed document is encoded into the certificate that implements the digital signature. The “Digital Identity Guidelines” established by the National Institute of Standards and Technology provide the details the first two steps. Finally, the digitally signature must be implemented in a way to ensure any change to the signed content can be detected. The technical aspects for security of digital signatures are based on Public Key Infrastructure (PKI) and result in a cryptographic operation that guarantees signer, authenticity, data integrity and non-repudiation of the signed documents. These technical details  differentiate a digital signature. These technology mechanisms enable you to know who signed the content and provide assurance that nothing has changed in the content since it was signed.  Below is a graphic to help you see the difference between an electronic and digital signature.

Three Key Differences Between Electronic Signatures and Digital Signatures

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Now that you understand the difference between electronic and digital signatures you may have more questions like “What are the technical standards used to apply digital signatures?” or “How can I start using digital signatures for my organization?” For answers to these questions, read our blog post on “Technical application of digital signatures in healthcare” and “Using MaxSignatures to digitally sign documents”.