Defining and Maintaining a Legal Electronic Health Record

Melissa Swanfeldt

Director, Marketing Division

MEDITECH

April 13, 2006

Agenda

• Introduction

• Defining the Legal Health Record

• Functionality for Maintaining a Legal EHR

• Considerations for Selecting an EHR System

• Resources

• Q & A

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.

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 patient’s illness, injury, treatment and clinical decisions made

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

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"

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

Other Considerations

• Alerts, reminders and pop-ups (clinical decision support)

• Continuity of Care Records (CCRs)

• Personal Health Records

• Interoperability (RHIOs)

Form a Team to Define Your Legal EHR

• Legal counsel

• Clinical and medical staff

• HIM

• I.T.

• Decision-makers

Functionality for Maintaining the Legal EHR

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

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

Documentation Principles

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

Considerations when selecting an EHR System that meets your legal requirements

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)

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)

Does the System Support:

• Your Community and Regional EHR requirements (RHIO)

• Future plans

“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.”

Reed D. Gelzer, MD, MPH, CHCC, HIMSS conference 2006

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.

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: What’s That You’re Wearing?” Reed D. Gelzer, MD, MPH, CHCC.

Contact Melissa Swanfeldt, Director, Marketing Division, MEDITECH: mswanfeldt@meditech.com