The Legal and Hybrid EHR

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(No Transcript)
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The Legal and Hybrid EHR June 21, 2007 By
Michelle Dougherty, RHIA, CHPDirector, Practice
LeadershipAHIMA
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Goals for this session

• Recognize the importance of electronic records
  management.
• Understand the concept of a hybrid record.
• Articulate why EHRs must serve as the legal
  business record

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True or False

• Maintaining the electronic medical record is an
  IT function?

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FALSE

• IT maintains the technical infrastructure, but
  electronic records and electronic content must be
  managed through their lifecycle just as paper
  records.

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Electronic Records Management

• the processes by which electronic (i.e.,
  digital) health records are created or received
  and preserved for evidentiary discovery (i.e.,
  legal / business) purposes. e-HIMTM Workgroup
  2004
• The requirements for EHRM remain the same as HRM
  (indeed, with some new wrinkles) only the
  processes change.

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Document Life Cycle From Stages of Creation
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Document Life Cycle Through Completion
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Document Life Cycle Through Preservation then
Destruction
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True or False

• In general, LTC has a hybrid medical record.

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TRUE

• A hybrid medical record
• Includes both paper and electronic documents
• Uses both manual and electronic processes
• How is the record hybrid in LTC and Post-Acute
  Care?

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Hybrid Medical Records

• Pros
• Provides an incremental transition to a fully
  electronic medical record
• Cons
• Some think this is a permanent state
• Risks to maintaining hybrid records
• Information is in too many places too many
  chances to have missed data during care delivery
  or to have conflicting data
• Goal Move to a fully electronic record as soon
  as possible during the transition phase

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Key Recommendation

• Organizations MUST define their medical record
  when it is in a hybrid and fully electronic
  state.
• What is considered part of the formal, legal
  record for disclosure purposes
• What is not part of the record
• What system does it reside in
• When were the transition dates (when did paper
  start and electronic start)
• Retention periods and destruction processes for
  medical record and discoverable
  records/electronic data

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True or False

• The clinical application (electronic record
  system) wont be utilized in litigation because
  courts only accept paper or printouts.

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FALSE

• Both paper and electronic records will be
  required for litigation
• The new Federal e-Discovery rule establishes a
  framework for electronically stored information
• e-discovery rules have started to change rules at
  the state court level

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True or False

• Organizations must define their legal health
  record.

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TRUE

• Organizations must understand what is their
  formal representation of the stay their legal
  medical record
• Must understand what information is not in the
  medical record, but may be discoverable.

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True or False

• EHR systems must have functionality that supports
  a legally sound EHR.

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TRUE

• An EHR must be able to create, maintain, and
  manage records within a framework of
  ever-changing jurisdictional rules, regulations,
  and laws that are intended to assure electronic
  records are valid, accurate, and trustworthy.
• Includes functionality to assure data quality and
  integrity for all purposes and end-uses of health
  care data.
• Admissible as evidence and holds up in court.

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Two Critical Components
Legally Sound EHR-System
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Regulatory Legal Concepts
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HIT Standards Organizations that Address Legal
EHR Concepts

• ISO
• ASTM
• Canada Health Infoway
• HL7 Messaging
• HL7 EHR Functional Model
• HL7 Legal EHR-S (LEHR-S) Functional Profile

NEW!
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Key Functionality in LEHR-S Profile

• Store and Manage Health Records
• Manage Record States
• pending,
• amended/corrected/augmented
• succession management,
• retracted
• Redaction
• Health Record Completeness
• Chronology of Events
• Replication of Views
• Downtime Procedures and Backup

• Security
• Authentication
• Authorization
• Access Control
• Non Repudiation
• Secure Data Exchange and Routing
• Information Attestation
• Privacy Confidentiality
• Health Record Information Management
• Retention, Availability and Destruction
• Legal Hold and Notice
• Auditable Records
• Metadata
• Extraction of Health Record Information
• Search and Retrieve

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Questions

• Thank You!
• michelle.dougherty_at_ahima.org
• [phone]