Understanding EHR
Regardless
of format, whether paper, hybrid, or electronic, the health record must meet
the requirements of the legal and business record for the organization.
Healthcare providers across the country recognize the
benefits of electronic health records (EHRs) to improve care, reduce costs and improve
efficiency. But as medical professionals, we know the challenges of keeping up
with technology. The Healthcare Information and Management Systems Society
(HIMSS) has developed some suggestions for you as you plan EHR implementation
for your practice.
WHAT IS THE LEGAL ELECTRONIC HEALTH RECORD (EHR)?
• The health record is a healthcare organization’s most important
business and legal record.
• Legal requirements, well defined for maintaining paper health
records, are additionally complex for electronic records.
• Health records must be maintained in a way that is legally sound
or they risk being challenged as invalid.
WHY DOES THE EHR
NEED TO BE A LEGAL RECORD?
Simply, a healthcare organization must have a
health record. Its “health record” must, by definition, meet all statutory,
regulatory, and professional requirements for clinical purposes as well as for
business purposes. If the record does not qualify as a legal record, it becomes
hearsay and therefore is much less legally valid for business or for
medical-legal purposes. Unless the practice intends to maintain separate paper
records that comply with legal requirements, its EHR, to be a legal record,
must conform to the same requirements as health records in general and for
business records on computers more specifically.
WHAT IF MY EHR DOES
NOT MEET THE REQUIREMENTS FOR A LEGAL RECORD?
• As an invalid business record, a problematic EHR can be challenged by payors for billing or Pay for Performance
(P4P).
• With an invalid medical-legal record, risk of adverse
litigation outcomes and costs rise.
LEGAL EHR BASICS
Don’t assume that a given EHR will meet your
requirements for a legal record. As the EHR marketplace increases awareness of
these matters, products will continue to improve. Here are four areas to look
at:
How
is documentation created?
• Is the author of each element of
documentation accurately recorded, including vitals, chief complaint, history
of present illness, orders, plans, and prescriptions?
• How are different, successive versions of
the encounter (before signature) treated?
• Do signature procedures and tools meet your
state’s and your organization’s requirements?
How
is documentation managed and preserved over time?
• After signature, if a correction,
clarification, or amendment is added, is it clear what is original and what is
not and can all original documentation be recovered if needed?
• How is documentation protected from being
altered, in all parts of the system including the underlying database?
• How are new templates, guidelines, forms,
etc., created, preserved, retired?
• Are all clinical messages and clinical
behaviors (prompts, etc.) reproducible and recoverable?
• Do other periodic and necessary tasks, such
as report creation and auditing, also expose documentation to additional security risks?
• Are critical support functions, such as
auditing, always operable and reasonably accesible or do they require vendor
supports or other extra costs?
How
does documentation interact with billing?
• Does the system prompt users to add
documentation for “improved revenue”?
• Does the system allow the sending of billing
information without completion of documentation?
• Does the system send billing information for
tests without means to ensure the tests were actually done?
How
is documentation presented?
• When asked to produce a view or a printout
of an encounter, does the system offer a view that conforms to your organization’s
definition of its legal record?
• If documentation has been amended or
otherwise altered, is that clearly identified in the viewed and printed
version?
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