Defining and Maintaining a Legal Electronic Health Record

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Defining and Maintaining a Legal Electronic
Health Record

• Melissa Swanfeldt
• Director, Marketing Division
• MEDITECH
• April 13, 2006

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Agenda

• Introduction
• Defining the Legal Health Record
• Functionality for Maintaining a Legal EHR
• Considerations for Selecting an EHR System
• Resources
• Q A

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Regardless of its format--paper, hybrid, or fully
electronic--the health record must meet the
requirements of the legal and business record for
the health care organization.
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The Roles of the Legal Health Record

• Support the decisions made in the patient's care
• Support the reimbursement practices of the
  organization
• Document the services provided as legal testimony
  of the patients illness, injury, treatment and
  clinical decisions made

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How Do You Define What Makes up Your Legal
Record?

• Data to be included (electronic data, documents,
  images, audio/video files)
• Records created in the ordinary course of
  business
• Create matrix of what makes up the Legal Record

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Considerations for Defining the Legal Health
Record

• HIPAA, CMS regulations, federal, state, and local
  laws
• Health care organization and medical staff bylaws
• Accrediting agencies
• Payor requirements
• "One size does not fit all"

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Conditions of Participation for
Hospitals482.24(c) Standard Content of Record

• The medical record contains written
  documentation, computerized information,
  radiology films/scans, lab reports
• The medical record documents planning for a
  patient's care and the decisions made on the
  provision of care
• It must contain documentation assessments to
  justify continued stay
• To support the diagnosis
• To describe the patient's progress
• To describe the patient's response to
• medications
• interventions
• services

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Other Considerations

• Alerts, reminders and pop-ups (clinical decision
  support)
• Continuity of Care Records (CCRs)
• Personal Health Records
• Interoperability (RHIOs)

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Form a Team to Define Your Legal EHR

• Legal counsel
• Clinical and medical staff
• HIM
• I.T.
• Decision-makers

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Functionality for Maintaining the Legal EHR
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The Comprehensive Guide to Electronic Health
Records

• Type of computer used and its acceptance as
  standard and efficient equipment
• The record's method of operation
• The method and circumstances of record
  preparation, including
• The sources of information on which it is based
• The procedures for entering information into and
  retrieving information from the computer
• The controls and checks used as well as the tests
  made to ensure the accuracy and reliability of
  record
• The information must not be altered

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Functionality for Maintaining the Legal EHR

• Authentication for legal admissibility
• Who may document in the record
• Data integrity, access, security, audit trails
• Output/printing
• Permanency, retention, purging, storage
• Business continuity and disaster recovery

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Documentation Principles

• Linking each patient to an entry
• Timeliness and chronology of entries
• Legibility and display
• Corrections, errors, and amendments
• Chart content
• Formats

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Considerations when selecting an EHR System that
meets your legal requirements
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Does the system support

• The level of security access you require (User
  ID, password length, smart card, biometrics)
• Role-based and/or user-based access
• Appropriate back-up protocol to ensure data
  recovery and business continuance
• Authentication requirements (date/time stamp,
  author, title, credentials, electronic signature,
  multiple signatures)

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Does the System Support

• Requirements for archiving and long-term storage
• Storage and access requirements for all
  components of the Legal EHR (i.e. PACS,
  multimedia files)

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Does the System Support

• Your Community and Regional EHR requirements
  (RHIO)
• Future plans

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Today, the HIM professional is an integrated
part of the team that maintains vigilance over
the health information technology realm, so that
health information management standards are
consistently applied across all systems in order
to maintain the level of integrity necessary for
the clinically and medically legal sound
operations of the health care organization. R
eed D. Gelzer, MD, MPH, CHCC, HIMSS
conference 2006
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Resources

• HL7 Workgroup for the Legal EHR www.hl7.org/ehr
• Certification Commission for Health Information
  Technology. www.cchit.org
• AHIMA. Update Maintaining a Legally Sound
  Health Record--Paper and Electronic. Journal of
  AHIMA 76, no.10.
• AHIMA. Update Guidelines for Defining the
  Legal Health Record for Disclosure Purposes.
  Journal of AHIMA 76, no8.

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Resources

• How to Select and Electronic Health Record
  System. Alder KG. Family Practice Management.
  Feb 2005, 55-62. http//www.aafp.org/fpm/20050200/
  55howt.html
• AHIMA. The Legal Process and Electronic Health
  Records. Journal of AHIMA 76, no.9 (Oct 2005).
• Hey Health I.T. Emperor Whats That Youre
  Wearing? Reed D. Gelzer, MD, MPH, CHCC.

Contact Melissa Swanfeldt, Director, Marketing
Division, MEDITECH mswanfeldt_at_meditech.com
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