HL7 EHR-S Records Management & Evidentiary Support Functional Profile
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1 HL7 EHR-S Records Management & Evidentiary Support Functional Profile Michelle Dougherty, RHIA, CHP HIT Standards AHIMA for the Legal EHR An educational update to the HIMSS EHR Implementation Task Force May 7,
2 Introduction to the RM-ES Functional Profile: An EHR-S must be able to create, receive, maintain, use and manage the disposition of records for evidentiary purposes related to business activities and transactions for an organization. One of the secondary uses for EHR data is medico-legal purposes ISO defines medico-legal purposes as evidence of care provided, indication of compliance with legislation, and reflection of the competence of clinicians. This profile establishes a framework of system functions and conformance criteria as a mechanism to support an organization in maintaining a legally-sound health record. Since legal validity is at stake for uses of electronic records for evidentiary purposes, including admissibility of medical records, the RM-ES profile is important to health care operations and to interoperability.
3 HIT Standards & Resources that Address Records Management & Evidentiary Support Concepts ISO ASTM Canada Health Infoway HL7 Messaging HL7 EHR Functional Model HL7 EHR-S Records Management and Evidentiary Support (RM-ES) Functional Profile CCHIT Sedona Conference Working Groups References (Legal Think Tank) Federal e-discovery Rule (Amendment to the Federal Rules of Civil Procedures)
4 What is a Functional Profile? What is a EHR-S functional profile? A statement of requirements for EHR systems tailored from the EHR Functional model. Used as a tool for providers, vendors, payers and others to identify specific functionality needs for a given purpose Can be used by CCHIT in specifying the EHR certification criteria that will by required of certified EHR systems in a specific setting. Used to inform future versions of the EHR-S Functional Model standard
5 Development of the RM-ES Functional Profile EHR TC had a Legal Workgroup new Workgroup developed functional profile Public comment in June 2007 Ballot as a draft standard in Dec 2007 Focus on the supporting functionality regardless of clinical content collected in an EHR-S Addresses core concepts of records management and evidentiary support Universal profile -- provides a foundation for jurisdictions to tailor based on specific rules, regulations or laws RM-ES profile added 16 new functions to the EHR-S FM
6 Key Functionality in EHR-S RM-ES Functional Profile
7 Security Authentication and Authorization User verification Access Control Non Repudiation Secure Data Exchange and Routing Information Attestation Electronic signatures/authentication Privacy & Confidentiality
8 Health Record Information & Management Retention, Availability and Destruction Preservation (such as a Legal Hold) Auditable Records Metadata System Application Point of Record Extraction of Health Record Information Search and Retrieve
9 Store and Manage Health Records Manage Record States Pending, Amended/corrected/augmented Succession management, Retracted Redaction Health Record Completeness Chronology of Events Replication of Views Downtime Procedures and Backup Reports & Health Record Output
10 Business Rules and Workflow Business Rules Audit record of changes Retention of business rules Workflow System use of task lists Retain and Destroy Audit Export rules
11 RM-ES Profile Ballot Period Out for ballot until January 5, 2008 Access at: Member or non-member* can vote/submit comments * Administrative fee for non-members
12 Thank you! For more information, please contact HIMSS Staff Liaison JoAnn W. Klinedinst, CPHIMS, PMP, FHIMSS at
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