Leslie: This month's column wraps up our three-part series on the legal EHR. Last month we discussed the legal challenges around genetic information with Barbara Fuller, JD, RHIA, assistant director for ethics, deputy ethics counselor, NationalHumanGenome Research Institute, National Institutes of Health (NIH).
Patty: This was such an interesting conversation about the treatment of DNA information. Highlights from this conversation include the three key topics for HIM professionals to have on their radar: 1) genetic non-discrimination laws, 2) release of genetic information and 3) special protections within the EHR for genetic test information.
Leslie: In Part 1, Michelle Dougherty, RHIA, director of practice leadership at the American Health Information Management Association (AHIMA) framed the dialogue around the legal EHR. Three themes emerged: 1) defining the legal EHR, 2) EHR system functionality required for a business record, and 3) disclosure processes. Michelle and Gwen Hughes also provided a great list of resources for HIM professionals to include in their legal EHR tool kit.
Gwen: I am going to join you again this month and suggest that we visit the topic of e-discovery, the disclosure of information in electronic form.
Patty: Good idea Gwen. This is a growing concern for HIM professionals, health care attorneys and risk managers in an era where the e-discovery rules for health care are just being played out in the legal process. We can look to the Federal Rules of Civil Procedures to guide current thinking on e-discovery as we lead our organizations in the development of processes that support e-discovery. Everything is fair game from e-mails, voice files and meta data, the data about data.
Gwen: Organizations are also evaluating to what extent EHR prompts and alerts are discoverable. It's likely that case law will determine how prompts and alerts will be handled in the future, but for now, it's important that provider organizations include how they treat prompts and alerts in their legal EHR definitions, specifically as it relates to when and how they store this information.
Leslie: It seems to me that it is very important that HIM professionals understand how data, including voice, pictures, videos and waveforms are collected, where they are stored within their organization and how to access that data. This information is likely to be asked during the discovery process. Given the nature of hybrid records and best of breed systems, it is likely that information is stored in multiple information systems.
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Source: http://www.advanceweb.com/
By: Leslie Ann Fox, MA, RHIA, and Patricia T. Sheridan, MBA, RHIA
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