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Ahima2010 Summer Presentation Writ Kohn
- 1. WHEN THE WRIT
HITS THE FAN:
MANAGING EHRs
AS BUSINESS RECORDS
Deborah Kohn
1 © 2007
- 2. Learning Objectives
1. Understand the importance of managing Electronic
Health Records (EHRs) as business records.
2. Manage the process of electronic records management
for evidentiary discovery purposes.
3. Review information systems capable of creating
electronic health records, such as eMail systems,
dynamic Web site systems, and PACS.
4. Create a comprehensive plan for the life cycle
management of the organization’s electronic business
records.
© 2007
- 4. Today’s Healthcare Organization
However, more digital / electronic
records are created than analog
records.
EVERY MINUTE:
servers log thousands of network interactions
staff members create hundreds of eMail
messages
databases record gigabytes of information
© 2007
- 5. Trade Off?
Digital / electronic records / film
might take up less physical space
than their predecessors, but they
remain business records that
might be subpoenaed for medical
malpractice lawsuits or other
legal actions.
© 2007
- 6. Managing Electronic Records/Film
As such, the management of
electronic records / film
requires the same rigorous
principles applied to analog
paper records / film.
© 2007
- 7. Way Back When… 1970s
Acknowledging Subpoenas
COURTS REQUIRED
The physical delivery of ―original,‖
analog source documents / records.
Only rudimentary paper photocopy
machines existed (thermo facsimiles)
© 2007
- 9. Way Back When… 1980s - 1990s
Acknowledging Subpoenas
COURTS ACCEPT
– Photocopies of ―original,‖ electronic
source documents and records
© 2007
- 10. 2010
Acknowledging Subpoenas
COURTS ACCEPT
– Secured electronic files of ―original,‖
electronic source documents and
records
– Hard copy computer printouts of
―original,‖ electronic source documents
and records
© 2007
- 11. 2010
Secured electronic files and hard copy
computer printouts are admissible in court as
long as the healthcare organization can
substantiate
– the trustworthiness of the system(s) used to store
and retrieve the documents and records
– the accuracy of the organization’s records
management policies and procedures
– the documents and records were not created just
for a court case.
It is important to verify the courts’ acceptance
of digital records on a state-by-state basis.
© 2007
- 12. 2010
Acknowledging the humungous
number of other requests for
Release of Information (RoI) /
Disclosure of Information
PATIENTS / ATTORNEYS / … ETC.
– Demanding and, in most cases, entitled
to ―any and all records‖ connected to
an episode of care
© 2007
- 13. No Longer Cardboard Boxes
Organizational intranets and Web portals
allowing designated Custodians of Records,
RoI professionals, and even patients —
after rigorous authorization and
authentication processes — to
click on hyperlinks
instantaneously retrieve ―original‖ electronic
source documents and objects required by
subpoenas or other requests
securely transmit them to the requesters
© 2007
- 14. Electronic Source Records
All related digital (electronic)
patient financial records from
financial data repositories
© 2007
- 15. Electronic Source Records
All related digital (electronic)
patient medical records from
clinical data repositories, such
as
acute care health records
ambulatory care health records
long-term care health record
mental health care records
© 2007
- 16. Electronic Source Records
Includes all related:
Digital ―conversations,‖ including
eMail messages, vMail messages, e-
annotations (the equivalent of
electronic Post-it notes), text
messages, and digitized telephone
consults
© 2007
- 17. Electronic Source Records
Includes all related:
Digital diagnostic images from
diagnostic image repositories,
including digital X-rays as well as
CT, MR, and nuclear medicine
© 2007
- 18. Electronic Source Records
Includes all related:
Cine, including cardiac
catheterization and ultrasound
images (video files) from video
repositories
Digital medical dictation (audio
files) from audio repositories
© 2007
- 19. Electronic Source Records
Includes all related:
Medical transcription (text files)
from text repositories
Digital photographs, including those
taken from pathology digital
cameras-on-a-stick
© 2007
- 20. Electronic Source Records
Includes all related:
Waveforms (signal trace or graphic
files) from signal trace repositories,
including ECGs, fetal traces, and
output from other electronic, point-
of-care medical devices
© 2007
- 21. Electronic Source Records
Handwritten Notes Laboratory Orders / Results
and Drawings
Orders / Medication Orders / MARs
Signed Patient
Online Charting
Consent Forms Original, and
Analog Discrete, Documentation
Documents- Structured
Document Data
Image Data Detailed
Radiology Charges
Reports Diagnostic
Text Data CT
Transcribed Image Data MR
Reports Video Ultrasound
Signal Nuclear Med
UBs and Data
Audio Tracing
Itemized Bills Data
Data Pathology
Ultrasound and Images
Cardiac Catheterization
EKG/EEG/Fetal
Examinations Heart Voice Dictations Monitoring Signal
Sounds & Annotations Tracings © 2007
- 22. Electronic Health Records
Encompass health information
recorded on any digital medium
as read-only or rewritable
formats
– Magnetic tape / disk
– WORM optical disk
– CD / DVD
© 2007
- 23. Electronic Health Records
Are evidence of transactions or
events that
– have legal or business value (i.e.,
the records reflect the business
objectives of the organization,
such as receiving reimbursement
for services provided)
– indicate an intention to be
memorialized
© 2007
- 25. Electronic Health Records =
Not Business Records
Reproductions of the electronic
records that are provided by the
organization to an individual or
another healthcare organization
for convenience purposes
© 2007
- 26. Electronic Health Records =
Not Business Records
Ad hoc or draft electronic record
documents, such as some eMail,
some vMail, some eAnnotations,
text messages, work sheets, work
lists, works-in-progress, and
database manipulations
© 2007
- 27. Electronic Health Records =
Not Business Records
Personal Health Records (PHRs),
which are patient owned,
managed, and populated -- and
might include copies of the
healthcare organization’s business
record files.
© 2007
- 28. Caveat?
BUSINESS RECORDS IF
the records are subsequently used by the
healthcare organization in evaluating or
treating the patient, such as providing care,
reviewing data, and documenting
observations, actions, or instructions
FOR EXAMPLE
patient-owned, managed, and populated
―tracking‖ records, such as electronic
medication tracking records, glucose and
insulin tracking records, etc.
© 2007
- 29. Caveat?
THE FEDERAL RULES OF CIVIL
PROCEDURE GOVERNING
ELECTRONIC DISCOVERY, effective
December 1, 2006.
For example:
© 2007
- 30. Caveat?
Rule 26 – the Rule that describes
the legal obligation to maintain and
disclose relevant records – specifies
that ―a party must now, without
awaiting a discovery request,
provide to other parties a copy of, or
description by category and location
of, electronically stored
information‖.
© 2007
- 31. Think About That …
Without awaiting a Discovery
Request
Provide a Copy of, or Description by
Category And
Location Of
Electronically Stored Information
CAN YOU DO THIS NOW?
© 2007
- 32. Electronic Records Management
The process by which
electronic records are created
and preserved for evidentiary
discovery (i.e., legal /
business) and, now, electronic
discovery purposes
© 2007
- 34. Electronic Record Decision Making
What electronic records to keep?
How long to keep?
How to assign record authorities and
responsibilities?
How to design the process?
How to administer the process?
How to audit the process?
How to review the process?
© 2007
- 35. Electronic Record Life Cycle
Creating / Receiving
Indexing
Searching
Retrieving
Processing
Routing / Distributing
Storing
Maintaining
Securing
Purging / Archiving / Destroying
© 2007
- 36. Health
Electronic ^ Records Management
Example healthcare information
systems capable of creating electronic
records and then processing,
distributing, maintaining, storing,
retrieving, archiving, and destroying
the records…
© 2007
- 37. Health
Electronic ^ Records Management
Patient billing and accounts
receivable systems
Healthcare information systems
Clinical information systems
© 2007
- 38. Health
Electronic ^ Records Management
Cardiology, laboratory, radiology, and
pharmacy information systems
Picture Archiving and
Communications Systems (PACS)
© 2007
- 39. Health
Electronic ^ Records Management
Digital dictation systems and speech
recognition systems
Word processing (i.e., transcription)
systems
© 2007
- 40. Health
Electronic ^ Records Management
Electronic document management
systems (EDMSs)
Report, print, and output management
systems (e.g., reproduction systems)
© 2007
- 41. Health
Electronic ^ Records Management
eMail systems (e.g., Microsoft
Outlook)
Collaboration systems (e.g., project
extranets and online conferencing
systems)
© 2007
- 43. Health
Electronic ^ Records Management
It’s now time for healthcare
organizations to address the new
challenges involved in the ongoing
maintenance and management of the
EHR.
This requires:
management strategies
knowledge and leadership skills to
shape and deploy the strategies
© 2007
- 44. Health
Electronic ^ Records Management
Creating and maintaining EHR retention and
disposition schedules based on administrative,
legal, fiscal, and historical needs
Establishing documented procedures for the
scheduled destruction of obsolete EHRs and
retaining proof of such destruction
Developing, implementing, and maintaining
efficient EHR filing systems
Quickly locating and organizing EHRs
© 2007
- 45. Health
Electronic ^ Records Management
Training personnel in the use and
function of EHR management processes
Ensuring the confidentiality, security, and
integrity of the information contained in
the EHRs
Monitoring / auditing the completeness
and accuracy of the EHR content
© 2007
- 46. Automated EHRM Functions
Record capture, where a predefined set of
metadata is established supporting
accurate representation of the record
with disciplined disposition and retention
actions
Record classification, where appropriate
categories of records are established with
applied rules
© 2007
- 47. Automated EHRM Functions
Record preservation format, where a
format, such as eXtensible mark-up
language (XML) or portable document
format (PDF), is established for retrieval
and cross-departmental interchange
Record retention calculation, where
―triggers‖ automatically save electronic
documents or Web content as records
according to pre-established business
rules
© 2007
- 48. Automated EHRM Functions
Record disposition control, where rules
provide electronic notifications to
managers that certain records or
documents have met their retention
dates and require manual confirmation
to delete, save, or destroy
Record deletion and destruction and
suspension of record deletion and
destruction to support litigation.
© 2007
- 49. Health
Electronic ^ Records Management
LONG TERM STRATEGIES
Develop a comprehensive plan for
EHR life cycle management
Incorporate the plan into the
organization’s IT strategic plan
Dictate the plan to the users
© 2007
- 50. Health
Electronic ^ Records Management
SHORT TERM PLANS
Develop EHR policy / procedure
guidelines for existing
information systems
Develop EHR policy / procedure
guidelines before buying new
EHR technologies / systems
© 2007
- 51. Health
Electronic ^ Records Management
• A ________ information system shall allow users
to create folder hierarchies, wherein users can
place electronic documents or records that contain
PHI.
• A ________ information system shall be capable of
automatically applying classification and retention
schedules that are established by the healthcare
organization.
• A ________ information system shall be capable of
taking Web site snapshots, allowing users to
record the sequence of the screens encountered
during a Web site transaction.
© 2007
- 52. Health
Electronic ^ Records Management
TECHNICAL CONSIDERATIONS
Identify all existing enterprise-wide
repositories that securely store EHR
records and documents which merit
evidentiary discovery handling
Move all inactive or semi-active files
to separate, secure storage
© 2007
- 53. Health
Electronic ^ Records Management
TECHNICAL CONSIDERATIONS
Implement a regular sweep of EHR
information to ensure that the archive
is kept accurate and up to date
Trawl the archive and assign retention
flags to information
© 2007
- 54. Health
Electronic ^ Records Management
TECHNICAL CONSIDERATIONS
Destroy unflagged files from the
archive
Manage large files and file types for
security purposes
© 2007
- 55. Health
Electronic ^ Records Management
COLLABORATION OF EXPERTS
Legal professionals
HIT professionals
HIM professionals
Risk / Compliance professionals
Clinical professionals
© 2007