E-Discovery: A Deposition for your Electronic Health Record

Transcription

1 E-Discovery: A Deposition for your Electronic Health Record Sponsored by 1915 N. Fine Ave #104 Fresno CA Phone: (559) Fax: (559) Program Handouts Wednesday, June 10, 2015 Track Two 9:20am-10:20am 2015 State Convention and Exhibit Speaker Diane Premeau, MBA, MCIS, RHIA, CHP, CHC Copyright California Health Information Association, AHIMA Affiliate

2 California Health Information Association California Health Information Association E DISCOVERY A Deposition for your Electronic Health Record Diane Premeau, MBA, MCIS, RHIA, RHIT, CHP, A.C.E. dianepremeau@dochs.org Speaker Disclaimer The author is not providing or offering legal advice but, rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality, and coding. Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying A l i best practice solutions and achieving i results will vary in each hospital/facility and clinical situation. The speaker is not promoting any service or product Copyright California Health Information Association, AHIMA affiliate 1

3 OBJECTIVES What s in a Deposition Prepare Today! Define E Discovery Identify Components of Legal Health Record from source systems Define your legal health record Create a source system review Understand importance to E Discovery What is E Discovery The process of preparing and presenting electronically ll managed information. Federal Rules of Civil Procedure (2006) (FRCP) allows for legal discovery in healthcare proceedings equal weight to paper and electronic information. Coordination of IT, HIM, and Legal counsel. Copyright California Health Information Association, AHIMA affiliate 2

4 Deposition: The Past Reality Check: The NEW Deposition The person most qualified about computerized system used by plaintiff to record medical information for patient s residing in the medical unit. The person most qualified about creation, preparation and modification of the computerized medical record. Person most qualified about the maintenance and preservation of computerized medical records for patients residing in the plaintiffs medical unit. Copyright California Health Information Association, AHIMA affiliate 3

5 Now WHAT??? Planning today for the What If is Critical! Identify Legal lhealth lthrecord Conduct Source System Reviews Identify your RESOURCES Creation, modification, maintenance Training, Competency LET s GET STARTED Identifying the HEALTH RECORD E.HR Systems E.HR Content Designated Record Set LEGAL HEALTH RECORD What is discoverable??? E Discovery Copyright California Health Information Association, AHIMA affiliate 4

6 What is a Legal Health Record? Information created, received or maintained by an organization that t is the business record of activities, operations Supports decisions made in patient care. Supports claims for revenue. Serves as legal testimony regarding g illness, injury, response to treatment, and caregiver decisions. Generated for healthcare and would be released upon request. What is the Business Record? A recording/record made or received in conjunction with a business purpose and preserved as evidence or because the information has value. Information is created, received and maintained about a person. (E Discovery) Must be maintained to comply with applicable regulations, accreditation standards, professional practice standards & legal standards. Copyright California Health Information Association, AHIMA affiliate 5

7 What is the Designated Record Set (DRS) (HIPAA ) A group of records maintained by or for a covered entity that is the: medical and billing records about individuals; enrollment, payments, claims records, medical management record systems maintained by or for a health plan (case management); information used in whole or in part by entity to make decisions about individuals. What about Hybrid Record? Information that is maintained in a variety of media, including paper and electronic. Comprised of both paper and electronic processes to collect, store, retrieve and utilize the information. Hybrid record is more difficult to define and manage as legal record. Copyright California Health Information Association, AHIMA affiliate 6

8 What is an Electronic Health Record (E.HR) Medical information compiled in a data gathering format (point of care) for retention and transfer of Protected Health Information (PHI) via secured, and/or encrypted communication options. Can generate a health record of a clinical encounter May provide clinical decision support, alerts, outcomes reporting, quality monitoring. Components that can be released can be variable. What is the Personal Health Record (PHR) An Individuals own record, maintained by the individual, id created tdby the individual id and health care providers. PHR is separate from and does not replace the legal health record. Can be incorporated into Legal Health Record. Individual owns and determines access rights. Copyright California Health Information Association, AHIMA affiliate 7

9 WHO IS THE CUSTODIAN Past: Director of HIM Present: Hybrid, E.HR Several custodians Direct Custodian (typically HIM) Data Owner or Steward Business Associate/ Third Parties Office Record and Systems Custodian And. Finding your Health Record? Define the location of your record from creation to storage Past: Chart order Present: Variety of Sources Best Practice Development a matrix (attachment) Track source system, location, retention, media, designated record set Identify content external to organization Copyright California Health Information Association, AHIMA affiliate 8

10 Hybrid Record Matrix IP Document (list all your documents) 1. ADMITTING INFO Inpatient Admission Registration sheet Conditions of Admission Code Status Orders Medication Consents Legal Status documents: Organ Donation Form 2 ADMINISTRATIVE DOCUMENTS Advance Directive Alert Form Advance Directives Acknowledgement Interfacility transfer sheet Health Facility Minor Release Report Discharge Summary Physician/Treatment Coordinator Discharge Summary Death Notice Death Certificate Worksheet Autopsy VIEWING LOCATION Paper/ EDM Paper/ EDM Source System SCANN ED Locatio n for Legal Record (P, E) Part of Design ated Record Set Created by Interface 1 Core System E Y Admitting System A Chart Script No E Y Transcripti on System A Where is the E Record? Defining Functionality FACT Systems generating health lthinformation are proliferating in health care. FACT Individual departments are deploying systems and may not consult HIM for document requirements HOW CAN THE CUSTODIAN VALIDATE THESE SYSTEMS? Copyright California Health Information Association, AHIMA affiliate 9

11 Source System Review Do you know how your record is created? FIND ALL Systems All media Conduct a SOURCE SYSTEM REVIEW Where, Who, What output? Do you have SPECIAL considerations? Mental Health, Custody, Children or?? Identify and Mitigate weak system functionality and System Administrators. Copyright California Health Information Association, AHIMA affiliate 10

12 Designated or Legal Health Record? Identify Record Content Understand DRS from LRS Designated Record Set Includes LHR PLUS medical and billing records; enrollment, payment, claims, health plan, decision making documents Legal Health Record Individually identifiable data in any medium collected and used in documenting healthcare services or health status. Excludes administrative, derived or aggregate data Copyright California Health Information Association, AHIMA affiliate 11

13 Components of Health Record Policy? Identify content of the Health records Business & legal record Administrative Clinical External Bills, Encounter forms Case Management Records Remittance advice (Designated Record Set Only) H&P; Orders; Progress Notes; Lab Reports/Diagnostics Nursing Documentation Therapies Authorizations/Consents Clinical Reports External patient care records PHR What about Audit Trails A. An audit trail is part of the metadata created around a document. It is composed of all transactions and activities, including access, associated with the health record. B. Elements of an audit trail may include date, time, nature of transaction or activity, and the individual or automated system linked to the transaction or activity. Copyright California Health Information Association, AHIMA affiliate 12

14 Getting Ready for E Discovery Discovery is the pre trial legal process of identifying and obtaining electronically stored information. What has to be considered: Text Images Voice Tape Legacy System Source Systems PDA s Databasesb Messages E mail Calendar Web Sites Meta Data Devices What is Electronic Stored Information (ESI) ESI is information created, manipulated, communicated, stored, and used in DIGITAL form. Utilizes Computer Hardware & Software Can C you locate & produce ESI??? DO you have a Litigation Response Team? Copyright California Health Information Association, AHIMA affiliate 13

15 ESI Things to Consider Who are your Record Custodians? Primary Direct Custodians (point of entry) Data Owners/ Stewards (oversee process) Business Associates (ISP, ASP, vendors) Official Record & System Custodians (HIM, IT) What Governs the Process? Policy Procedures; Training Records Downtime Logs; Record Retention Back up Media; Putting it all Together for E Discovery Know: Who is on your litigation response team Organizational Information Management Plan Health Record Grid with LHR, DHR, Source System Source System Review Information Enterprise Record Retention Schedule Data Owners and Stewards Organization policy for E Discovery Who will place a legal hold on data How staff is educated on E Discovery Compliance Copyright California Health Information Association, AHIMA affiliate 14

16 Resources/Reference List AHIMA. "Fundamentals of the Legal Health Record and Designated Record Set." Journal of AHIMA 82, no.2 (February 2011): expanded online version. Dougherty, Michelle, and Lydia Washington. "Defining and Disclosing the Designated Record Set and the Legal Health Record." Journal of AHIMA 79, no. 4 (Apr. 2008): Available online in the AHIMA Body of Knowledge at Servais, Cheryl E. The Legal Health Record. Chicago, IL: AHIMA, Deleting Errors in the EHR (AHIMA September 2010, Working Smart) AHIMA e Discovery Task kf Force. "Litigation Response Planning and Policies for E Discovery." Journal of AHIMA 79, no.2 (February 2008): Legal Electronic Health Record Policy Template. Body Of Knowledge Questions Copyright California Health Information Association, AHIMA affiliate 15