consumer informatics - essentials in health informatics
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AB120015_Ch14.pptxIntroduction to Healthcare Informatics, Second Edition
Chapter 14:
The Legal Electronic Health Record
© 2017 American Health Information Management Association
© 2017 American Health Information Management Association
Objectives
Explain the legal health record for disclosure
Compare and contrast a paper-based legal health record, a hybrid legal health record, and an electronic legal electronic health record
Determine the stakeholders and their roles for electronic legal health record definition projects
Relate the steps involved in defining the legal health record
© 2017 American Health Information Management Association
Objectives (continued)
Articulate the importance of developing a legal health record policy
Interpret the attributes that can impact the legal health record definition and e-discovery
Analyze patient record documentation regulations for correct utilization within legal health record policies and procedures
© 2017 American Health Information Management Association
Legal Health Records (LHRs)
Describes the data, documents, reports, and information that comprise the formal business record(s) of any healthcare organization that are to be utilized during legal proceedings
No standard terminology
Recommend using legal health record defined for disclosure
Dynamic process
© 2017 American Health Information Management Association
LHR Governance
Laws—passed by legislatures
Rules and Regulations—interpretations of laws
Judicial Decisions—courts interpreting the laws
Precedence—Previous decisions
© 2017 American Health Information Management Association
Legal Processes
e-discovery—processes related to electronically maintained information
Federal Rules of Civil Procedure (FRCP)
Govern the procedures for civil trials
Often also used to guide state court civil procedures
State laws vary for subpoenas, court orders, discovery, and similar processes
© 2017 American Health Information Management Association
Federal Rules of Evidence
Govern what and how electronic records may be used in a trial
Roles of record custodianship for purposes of evidence in a trial
Electronic records have many more requirements than paper records
© 2017 American Health Information Management Association
LHR Stakeholders
C-suite and practice managers
HIM professionals
Information technology staff
Record custodians
Privacy, compliance, and security officers: risk managers and quality managers
Clinicians
Legal counsel
© 2017 American Health Information Management Association
Legal Health Records
Format:
Paper
Electronic
Hybrid
Health record custodian
Designated record set
© 2017 American Health Information Management Association
Purpose of LHR Definition
Clarifies the roles of all records and their uses
Sets foundational policy for record management operations
Must be continually reviewed and updated as their constituent record components evolve
© 2017 American Health Information Management Association
LHR Definition Project Steps
Determine the LHR stakeholder team
Determine strategy and plan; get executive sponsorship and empowerment
Gather LHR-related knowledge
Develop a master source system matrix
Create a document matrix of LHR components
© 2017 American Health Information Management Association
LHR Definition Project Steps (continued)
Assess and catalog EHR systems for their LHR attributes
Determine the need for new and revised related policies and procedures
Determine the LHR maintenance plan
Create a presentation and conduct education and training for appropriate workforce members
© 2017 American Health Information Management Association
LHR Defined for Disclosure
Determine what business records or components of records will be released upon legal request
Use a spreadsheet or other tool to keep track of source systems and documents
HIPAA Designated Record Set is a good starting point for the LHR
© 2017 American Health Information Management Association
LHR Policy Imperative
Determines what data and information can or should be released pursuant to a request from a third party
No policy leaves the organization at risk related to request for data and information that the organization is not prepare to release
© 2017 American Health Information Management Association
Litigation Response Policy
The processes invoked if the potential for lawsuits or litigation is detected
Maximize defensive posture
Responses to subpoenas and court orders
Protecting against spoliation (malicious alteration, concealment, or destruction of evidence)
© 2017 American Health Information Management Association
Uniform Rules for e-Discovery
Amendments to the FRCP specifically designed for electronically store information
Apply to federal courts, but can be followed as guidance
© 2017 American Health Information Management Association
Litigation Response Policies and Procedures
Failure to define these can increase liability and financial risk
Starts with documentation of the steps and personnel already performing these tasks
Customize practices to fit your specific requirements
© 2017 American Health Information Management Association
EHR System Functionality Relevant to the LHR
Audit logs
Authorship and authentication of entries and electronic signatures
Business continuity
Business rules
Data, document management, and nonrepudiation
Retention, data permanence, and migration plans
© 2017 American Health Information Management Association
EHR System Functionality Relevant to the LHR (continued)
Interfaces
Legal hold
Metadata
Electronic health record output
Rendition
Snapshots and screen views
Privacy attributes
Version controls
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Patient Record Documentation
Accuracy
Patient-requested amendments
Corrections
Deletions
Copy and paste forward
Late entries
Resequencing and reassignment
Templates, boilerplates, canned text, and structured input
© 2017 American Health Information Management Association
e-Discovery Overview
LHR needs to be defined
Disclosure—output and release upon request of appropriate health record documents
E-discovery—process of discovering the relevant parts of a patient’s record that may be used for litigation
© 2017 American Health Information Management Association
