HIM professionals play a variety of critical roles in the transition from paper to electronic records and the management of electronic content. AHIMA is developing new practice guidelines through the e-HIM initiative to assist with the transition. There are many important healthcare industry activities focused on the electronic health record. AHIMA strives to bring the HIM perspective to the groups and initiatives we monitor and participate.

Definition: What is the "legal EHR"?

The term “legal EHR” gained use largely for lack of a better term. It has been confusing because it has a different connotation depending on professional perspective.

For HIM professionals, the “legal record” refers to that data and information constituting the official record of care that is disclosed externally for continuity of care and other required business and purposes. An official record of care is required by regulation, has specified content, is retained for a period of time, and follows accepted practices for maintaining integrity.

This regulation enables the disclosure and use of the information for a host of new purposes such as health information exchange and personal health records as well as existing purposes such as demonstrating medical necessity, billing compliance, quality reporting, research, public health, accreditation, and legal requirements.

The term “legal EHR” evolved from the term “legal health record.” Originally HIM professionals were concerned primarily with identifying the data and information in early EHR systems that constituted the official record of care—the information that would be disclosed externally for continuity of care and other business purposes when requested.

However, it soon became apparent that the design of EHR systems presented many more complex challenges that risked the authenticity and integrity of the health information contained in these systems and affected their ability to be used for business, regulatory, and legal purposes.

The Legal EHR and content and records management are important initiatives to AHIMA and HIM professionals, specifically in our work to promote the need for EHR systems that create, receive, maintain, use and manage the disposition of records for business and evidentiary purposes. HIM professionals must collaborate with clinical, legal, and information technology professionals to address record lifecycle management that supports the legal and business uses of the health record.

Industry and Standards Activities

• ARRA/HITECH
  National policy for HIT and EHRs is shaped in part by the activities, priorities and incentives under the ARRA and HITECH. Two Federal Advisory Committees (FACAs) have been established to make recommendations to the Office of the National Coordinator for Health IT. AHIMA monitors the activities and recommendations. The direction established by the FACAs also impacts the activities and priorities of other standards and industry groups such as HITSP, CCHIT, HL7 and others.
• Health IT Policy Committee
• Health IT Standards Committee
  
• Health Information Technology Standards Panel
  HITSP's objective is to achieve widely accepted and readily-implemented consensus-based standards that will enable and support widespread interoperability among healthcare information technology, especially as they would interact in a Nationwide Health Information Network (NHIN) for the United States. HITSP identifies, prioritizes and promotes relevant standards using patient-focused "use-case" scenarios.
  
• Health Level 7 EHR-System Standards
  Health Level 7 (HL7) is a HIT standards organization traditionally focused on messaging and exchange of data and documents. The goal of the EHR Technical Committee is to further the HL7 mission of designing standards to support the exchange of information for clinical decisions and treatments, and help lay the groundwork for nationwide interoperability by providing common language parameters that can be used in developing systems that support electronic records.
• EHR-System Functional Standard - ANSI-approved standard which outlines the functional requirements for EHR systems.
• EHR Functional Profiles - Profiles are being developed from the EHR-S functional standard. Profiles are developed for a specific purpose by identifying and tailoring functional requirements and conformance criteria for a specific purpose. Profiles are registered with the HL7 EHR technical committee. The following profiles have been registered or are under development.
• Emergency Department (Registered)
• Record Management & Evidentiary Support (Balloted September 2008)
• Behavioral Health (Balloted July 2008)
• Long Term Care (Balloted January 2009)
• Child Health (Balloted December 2007)

• Certification Commission for Health Information Technology (CCHIT)
  CCHIT is a certification body for electronic health record systems and their networks. It is an independent, voluntary, private sector initiative. The mission is to accelerate the adoption of health information technology by creating an efficient, credible and sustainable certification program. CCHIT is composed of commissioners from a variety of healthcare stakeholders and consists of work groups for the development and refinement of certification criteria.
  
  CCHIT is certifying EHR products in ambulatory care, emergency departments, and inpatient hospitals. CCHIT has many workgroups to support the development of the certification criteria and a roadmap to identifies the healthcare markets/segments in which certification will be offered in the future.
  
  AHIMA monitors the various workgroups and submits comments regularly to provide expertise and input in the certification criteria.
• Healthcare Anti-Fraud/Fraud Management
  Under contract with the Office of the National Coordinator for Health IT (ONC) the Foundation of Research and Education (FORE) of AHIMA published two reports on October 17, 2005 detailing how health information technology can address the growing problem of healthcare fraud. Two reports were released:
• Automated Coding Software: Development and Use to Enhance Anti-Fraud Activities
• Report on the Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities

In 2006-2007 Research Triangle Institute (RTI) received a contract from the Office of the National Coordinator to identify requirements for EHR-S that can help enhance data protections which would prevent fraud from occurring, as well as detect fraud both prospectively and retrospectively. A key component of the contract was to create recommended requirements that overlap whenever possible with those requirements currently in use for EHR certification. FORE/AHIMA was a subcontractor on this contract. One report was released and is available on the RTI website.

• Recommended Requirements for Enhancing Data Quality in Electronic Health Records

Resources & Links

Electronic Health Records

• NIST publishes EHR study on workflow 
• Office of the National Coordinator for Health IT
• Institute of Medicine Reports
• To Err is Human: Building a Safer Health System (November 1999)
• Crossing the Quality Chasm: A New Health System for the 21st Century (March 2001)
• Healthcare Information Management Systems Society (HIMSS)
• American Medical Informatics Association (AMIA)

e-Discovery

• The Sedona Conference® (A Legal Think Tank)
• The Sedona Principles Addressing Electronic Document Production, Second Edition (June, 2007)
• The Sedona Conference® Commentary on Legal Holds, August 2007 Public Comment Version
• The Sedona Conference® Commentary on Email Management (August, 2007)
• The Sedona Conference® Best Practices Commentary on Search & Retrieval Methods (August, 2007)
• Electronic Discovery Reference Model (EDRM)

Content and Records Management

• ARMA International - Records Management Association
• AIIM - The Enterprise Content Management Association

AHIMA Tools & Resources

• Practice Guidance from the AHIMA Compendium
• Access all AHIMA Resources on Electronic Health Records