June 25, 2007

Legally Speaking
By Denise Dunyak, MS, RHIA
For The Record
Vol. 19 No. 13 P. 10

Adapting to the changing HIM environment and evolving EHR while protecting the legal health record.

Having worked at length in the hospital and vendor HIM environments, I have watched the
components of the electronic health record (EHR) grow from the early stages, including the industry’s move from typewritten facesheets and computer entry on “dumb terminals” to today’s use of enterprise master patient indexes and smart card technology—all to help ensure that the documentation of the patient’s journey begins with a strong foundation.

In 2004, President Bush accepted the findings of the President’s Information Technology Advisory Committee (PITAC), which showed that electronic medical records (EMRs) could make healthcare more effective, cost-efficient, and accessible to consumers. Three years after a federal call for most Americans to have EMRs within one decade, progress is slowly and surely being made. The most recent efforts involve the certification of EMR systems.

Many solution providers offer state-of-the-art technology with the clinicians’ best interests in mind, which enable organizations to move toward EHRs. However, as we are learning in the HIM field, progressing to electronic health requires redefining and supporting the “legal health record.” The AHIMA has recently made headlines with its efforts to provide guidance for defining the legal health record in context with, and as a part of, EHRs.

Historically, in a manual environment, the legal health record was the record located on the shelves in the HIM department, post patient discharge. But today, defining electronic legal health records presents new challenges. While some organizations choose the monumental task of implementing electronic legal health records simultaneously across their entire organization, most organizations phase in the system over a period of time.

Phased implementation of electronic legal health records requires a hybrid (electronic and paper) environment until the manual paper-based process becomes redundant and can eventually be dramatically reduced or, ideally, eliminated. Storing, managing, viewing, and accessing the legal health record in the hybrid environment can also be challenging. The electronic patient information may be in a variety of clinical systems, including a clinical repository or within document imaging.

The AHIMA defines the legal health record as “generated at or for a healthcare organization as its business record and is the record that would be released upon request. The custodian of the legal health record is the health information manager in collaboration with information technology personnel. HIM professionals oversee the operational functions related to collecting, protecting, and archiving the legal health record, while information technology staff manages the technical infrastructure of the electronic health record.”

The legal health record comprises records of care in any healthcare-related setting used by healthcare professionals while providing patient care services, reviewing patient data, or documenting observations, actions, or instructions. The legal health record supports all HIM work, such as coding, release of information, research, and substantiation of care. The specific content of the actual legal health record varies based on governing organizations, such as The Joint Commission and Centers for Medicare & Medicaid Services, as well as individual state law and healthcare services provided; therefore, there is no standardized definition for legal health records.

While each organization must define the contents and retention schedules of their legal medical record, HIT vendors provide solutions to enable the creation of a paperless medical record as a stepping stone toward the EHR, as well as tools to help manage medical record compliance. Those solutions are also critical in the managing, accessing, and viewing of the legal health record. They include the clinical repositories of the various HIT solutions, which create the core information necessary to manage patient information throughout the healthcare network, as well as document management solutions to manage information that is still paper based. Each application manages patient information and supports specific operational needs and workflows to support the care team and HIM personnel.

Numerous approaches exist for healthcare organizations to consider when moving from paper-based documents to electronic solutions. One option stores all data comprising the legal health record within HIT solutions designed with the legal health record in mind, such as a document management solution. While there is redundant storage of some data, accessing the information for release and legal purposes is efficient as the information is accessible from one location. Document pointers may be stored in a clinical repository that offers the care provider a complete view of the patient’s record.

Another option organizations may consider involves the single storage of data in either the clinical repository or the document management solution. Using the clinical archive as the legal health record requires nonstructured, supplemental data to generate the complete legal health record. HIM workflow for coding, completion, and release of information may require the user to access data from structured clinical data sources, as well as nonstructured documents from the document management archive.

For the EHR to be successful, the legal health record must be fully considered as organizations plan their EHR solution. Today, state-of-the-art technology can enable organizations to efficiently and effectively move to the electronic legal health record. However, organizations implementing these solutions must work with their implementation team to ensure that they are making decisions specific to, and that best meet the needs of, their facility and its legal health record definition based on what solutions are being implemented and in what time frame.

— Denise Dunyak, MS, RHIA, leads the global marketing efforts for Soarian HIM and EDM solutions at Siemens Medical Solutions.