STANDARDS AND LAWS NEEDED TO ENSURE EHR MEETS REQUIREMENTS OF LEGAL MEDICAL RECORD
AHIMA applauds conformance criteria in HL7’s revisions to the EHR standard

CHICAGO, July 14—As healthcare organizations move to adopt electronic health records (EHR’s), it is imperative that new EHR systems are capable of producing a patient medical record that meets the requirements of a legal record according to the American Health Information Management Association (AHIMA).

“In addition to supporting the clinical care process, the EHR must serve as the legal medical record,” says Harry Rhodes, AHIMA’s director of practice leadership. “Unfortunately, the reality is that few healthcare organizations have a definition for their electronic legal medical record so they still keep paper records around to meet their legal requirements.”
One of the challenges of producing a legal medical record in an EHR environment is that existing definitions and standards for a paper-based legal medical record need to be adapted to the multimedia environment of the EHR. In addition, new standards are needed as technology dramatically changes the face of clinical documentation. How these standards are incorporated into the EHR vary due to the development path of a given vendor or internal IT department.

Health Level Seven’s (HL7) Electronic Health Record (EHR) Technical Committee (TC) recently announced an enhanced draft EHR System (EHR-S) Functional Model to include conformance criteria for a legal EHR. “This conformance criteria helps EHR vendors understand what functions and features will allow their products to meet the industry’s need to define and maintain a legal EHR, says Rhodes, also facilitator of the Legal EHR Expert Panel. “In the end, everybody wins.”

In addition to the need for updated standards, state laws governing the composition of legal medical records often don’t yet reflect the increasingly electronic environment. “The states acknowledge the validity of EHR’s, but they’re not out front in describing it,” says Ed Shay, partner in the Philadelphia-based law firm Post & Schell and vice chair of the health information and technology practice group of the American Health Lawyers Association. “What constitutes the legal record varies from state to state and institution to institution.”

AHIMA has assembled three workgroups of industry experts to identify the issues in establishing an EHR system as the legal record and to develop materials to accelerate the process. “Our goal is to build practical tools and professional guidance from the conformance criteria developed by HL7 to address issues of a legal EHR system,” says Michelle Dougherty, AHIMA’s manager of practice leadership. “In the end, regardless of the format, a sound legal medical record still needs to be complete and accurate, and reflect consistent data.”

The workgroup’s deliverables—which will include resources related to defining the legal EHR, maintaining a legal EHR, and the legal process—will be released to the industry starting in September 2005.

AHIMA is the premier association of health information management (HIM) professionals. AHIMA's 53,000 members are dedicated to the effective management of personal health information needed to deliver quality healthcare to the public. Founded in 1928 to improve the quality of medical records, AHIMA is committed to advancing the HIM profession in an increasingly electronic and global environment through leadership in advocacy, education, certification, and lifelong learning.