Ahima2010 Summer Presentation Writ Kohn
-
Upload
deborah-kohn -
Category
Documents
-
view
64 -
download
2
Transcript of Ahima2010 Summer Presentation Writ Kohn
1© 2007
WHEN THE WRITHITS THE FAN:
MANAGING EHRs AS BUSINESS RECORDS
Deborah Kohn
© 2007
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
Mounds of analog paper and film records still exist.
Today’s Healthcare Organization
© 2007
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
Today’s Healthcare Organization
© 2007
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
As such, the management of electronic records / film requires the same rigorous principles applied to analog paper records / film.
Managing Electronic Records/Film
© 2007
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
Deborah’s cardboard box approach!
Way Back When… 1970s
© 2007
Way Back When… 1980s - 1990s
Acknowledging Subpoenas
COURTS ACCEPT
– Photocopies of “original,” electronic source documents and records
© 2007
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
2010
© 2007
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.
2010
© 2007
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
2010
© 2007
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
No Longer Cardboard Boxes
© 2007
Electronic Source Records
All related digital (electronic) patient financial records from financial data repositories
© 2007
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
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
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
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
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
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
Signed PatientConsent Forms
TranscribedReports
Ultrasound andCardiac Catheterization
Examinations
Text Data
VideoData
AudioData
SignalTracing
Data
DiagnosticImage Data
Discrete,Structured
Data
Original,Analog
Documents-DocumentImage Data
Handwritten Notesand Drawings
RadiologyReports
UBs andItemized Bills
HeartSounds
EKG/EEG/FetalMonitoring Signal
Tracings
PathologyImages
CTMRUltrasoundNuclear Med
Laboratory Orders / Results
Orders / Medication Orders / MARs
Online Chartingand
Documentation
DetailedCharges
Voice Dictations& Annotations
Electronic Source Records
© 2007
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
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
Subject to Evidentiary Discovery
Electronic Health Records = Business Records
© 2007
Reproductions of the electronic records that are provided by the organization to an individual or another healthcare organization for convenience purposes
Electronic Health Records = Not Business Records
© 2007
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
Electronic Health Records = Not Business Records
© 2007
Personal Health Records (PHRs), which are patient owned, managed, and populated -- and might include copies of the healthcare organization’s business record files.
Electronic Health Records = Not Business Records
© 2007
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
Caveat?
THE FEDERAL RULES OF CIVIL PROCEDURE GOVERNING ELECTRONIC DISCOVERY, effective December 1, 2006.
For example:
© 2007
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
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
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
Electronic Records Management
Requires astute decision making throughout the life cycle of the electronic record
© 2007
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
Electronic Record Life Cycle Creating / Receiving Indexing Searching Retrieving Processing Routing / Distributing Storing Maintaining Securing Purging / Archiving /
Destroying
© 2007
Example healthcare information systems capable of creating electronic records and then processing, distributing, maintaining, storing, retrieving, archiving, and destroying the records…
HealthElectronic ^ Records
Management
© 2007
Patient billing and accounts receivable systems
Healthcare information systems
Clinical information systems
HealthElectronic ^ Records
Management
© 2007
Cardiology, laboratory, radiology, and pharmacy information systems
Picture Archiving and Communications Systems (PACS)
HealthElectronic ^ Records
Management
© 2007
Digital dictation systems and speech recognition systems
Word processing (i.e., transcription) systems
HealthElectronic ^ Records
Management
© 2007
Electronic document management systems (EDMSs)
Report, print, and output management systems (e.g., reproduction systems)
HealthElectronic ^ Records
Management
© 2007
eMail systems (e.g., Microsoft Outlook)
Collaboration systems (e.g., project extranets and online conferencing systems)
HealthElectronic ^ Records
Management
© 2007
Dynamic Web site systems with online forms, transactions, and metadata
HealthElectronic ^ Records
Management
© 2007
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
HealthElectronic ^ Records
Management
© 2007
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
HealthElectronic ^ Records
Management
© 2007
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
HealthElectronic ^ Records
Management
© 2007
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
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
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
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
HealthElectronic ^ Records
Management
© 2007
SHORT TERM PLANS
Develop EHR policy / procedure guidelines for existing information systems
Develop EHR policy / procedure guidelines before buying new EHR technologies / systems
HealthElectronic ^ Records
Management
© 2007
• 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.
HealthElectronic ^ Records
Management
© 2007
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
HealthElectronic ^ Records
Management
© 2007
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
HealthElectronic ^ Records
Management
© 2007
TECHNICAL CONSIDERATIONS
Destroy unflagged files from the archive
Manage large files and file types for security purposes
HealthElectronic ^ Records
Management
© 2007
COLLABORATION OF EXPERTS
Legal professionals HIT professionals HIM professionals Risk / Compliance
professionals Clinical professionals
HealthElectronic ^ Records
Management