ORGANIZATIONS WITH EHR'S MUST ADDRESS NEW LEGAL PROCESS ISSUES

CHICAGO, September 29—When a health record is involved in litigation, the custodian of that record may be asked to testify as to how the record was created, maintained, and whether the complete record had been turned over. As healthcare organizations move from paper to fully electronic health records (EHR) this has become a challenge as an EHR may consist of different data types, formats, and media.

“The custodian of an EHR has a number of additional concerns when a patient’s record is involved in litigation—including whether any differences exist between releasing patient data maintained electronically from that maintained on paper, what parts of the EHR should be released, and whether printouts of electronic data qualify as admissible evidence,”” states Susan Manning, JD, RHIA, CPC, healthcare consultant and co-chair of the American Health Information Management Association’s (AHIMA) e-HIM® workgroup. “Healthcare organizations must ensure that there are defined policies, audit trails, and controls in place.”

In the October issue of the Journal of AHIMA, the Association’s e-HIM® workgroup provides guidance on an EHR custodian’s responsibilities when involved in the legal process, including:

• Authentication for legal process—if allowed by state, federal, and reimbursement regulations, electronic signatures are acceptable as authentication and should provide verification of the identity of the author.
• Determining if health information may be disclosed—since federal and state laws will be challenged with the need to address the electronic disclosure of protected health information, routine assessment of acceptable alternative options to comply is recommended.
• Information that may be disclosed for the discovery process—paper is no longer the only documentation to be disclosed as computer files, erased files, and e-mail can also be subpoenaed.
• Printing documents—the printed document policy must include the formal process for access and printing from an EHR. Additionally, the policy should designate where copies of an EHR may be printed in an organization coupled with methods to control or dispose of paper copies immediately following authorized use.

Additional information can be found in the workgroup’s complete practice brief, “The Legal Process and Electronic Health Records,” on AHIMA’s Web site at http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_028134.hcsp.

The e-HIM® work group consisted of AHIMA members from various provider settings, law practices, information technology vendors, and information systems consultants. AHIMA provides its industry-leading e-HIM® education and advocacy programs to support the effective use of information technology to manage patient information and healthcare data. The workgroup was funded by a grant to the Foundation of Research and Education (FORE) from Precyse Solutions.

FORE provides financial and intellectual resources to sustain and recognize continuous innovation and advances in HIM for the betterment of the profession, healthcare, and the public. For more information about FORE, go to www.ahima.org/fore.

AHIMA is the premier association of health information management (HIM) professionals. AHIMA’s 52,000 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. For information about the association, go to www.ahima.org.