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1 © 2007 WHEN THE WRIT HITS THE FAN: MANAGING EHRs AS BUSINESS RECORDS Deborah Kohn

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Page 1: Ahima2010 Summer Presentation Writ Kohn

1© 2007

WHEN THE WRITHITS THE FAN:

MANAGING EHRs AS BUSINESS RECORDS

Deborah Kohn

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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.

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Mounds of analog paper and film records still exist.

Today’s Healthcare Organization

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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

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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.

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As such, the management of electronic records / film requires the same rigorous principles applied to analog paper records / film.

Managing Electronic Records/Film

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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)

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Deborah’s cardboard box approach!

Way Back When… 1970s

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Way Back When… 1980s - 1990s

Acknowledging Subpoenas

COURTS ACCEPT

– Photocopies of “original,” electronic source documents and records

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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

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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

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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

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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

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Electronic Source Records

All related digital (electronic) patient financial records from financial data repositories

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Subject to Evidentiary Discovery

Electronic Health Records = Business Records

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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

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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

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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

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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.

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Caveat?

THE FEDERAL RULES OF CIVIL PROCEDURE GOVERNING ELECTRONIC DISCOVERY, effective December 1, 2006.

For example:

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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”.

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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?

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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

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Electronic Records Management

Requires astute decision making throughout the life cycle of the electronic record

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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?

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Electronic Record Life Cycle Creating / Receiving Indexing Searching Retrieving Processing Routing / Distributing Storing Maintaining Securing Purging / Archiving /

Destroying

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Example healthcare information systems capable of creating electronic records and then processing, distributing, maintaining, storing, retrieving, archiving, and destroying the records…

HealthElectronic ^ Records

Management

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Patient billing and accounts receivable systems

Healthcare information systems

Clinical information systems

HealthElectronic ^ Records

Management

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Cardiology, laboratory, radiology, and pharmacy information systems

Picture Archiving and Communications Systems (PACS)

HealthElectronic ^ Records

Management

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Digital dictation systems and speech recognition systems

Word processing (i.e., transcription) systems

HealthElectronic ^ Records

Management

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Electronic document management systems (EDMSs)

Report, print, and output management systems (e.g., reproduction systems)

HealthElectronic ^ Records

Management

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eMail systems (e.g., Microsoft Outlook)

Collaboration systems (e.g., project extranets and online conferencing systems)

HealthElectronic ^ Records

Management

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Dynamic Web site systems with online forms, transactions, and metadata

HealthElectronic ^ Records

Management

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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

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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

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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

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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

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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

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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.

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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

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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

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• 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

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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

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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

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TECHNICAL CONSIDERATIONS

Destroy unflagged files from the archive

Manage large files and file types for security purposes

HealthElectronic ^ Records

Management

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COLLABORATION OF EXPERTS

Legal professionals HIT professionals HIM professionals Risk / Compliance

professionals Clinical professionals

HealthElectronic ^ Records

Management

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Questions & Answers

[email protected]

www.daksystemsconsulting.com