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

2. 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.
© 2007

3. Today’s Healthcare Organization
Mounds of analog paper and film records
still exist.
© 2007

4. Today’s Healthcare Organization
 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
© 2007

5. 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.
© 2007

6. Managing Electronic Records/Film
 As such, the management of
electronic records / film
requires the same rigorous
principles applied to analog
paper records / film.
© 2007

7. 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)
© 2007

8. Way Back When… 1970s
Deborah’s cardboard box approach!
© 2007

9. Way Back When… 1980s - 1990s
 Acknowledging Subpoenas
COURTS ACCEPT
– Photocopies of ―original,‖ electronic
source documents and records
© 2007

10. 2010
 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
© 2007

11. 2010
 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.
© 2007

12. 2010
 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
© 2007

13. No Longer Cardboard Boxes
 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
© 2007

14. Electronic Source Records
 All related digital (electronic)
patient financial records from
financial data repositories
© 2007

15. 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
© 2007

16. 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
© 2007

17. 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
© 2007

18. 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
© 2007

19. 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
© 2007

20. 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
© 2007

21. Electronic Source Records
Handwritten Notes Laboratory Orders / Results
and Drawings
Orders / Medication Orders / MARs
Signed Patient
Online Charting
Consent Forms Original, and
Analog Discrete, Documentation
Documents- Structured
Document Data
Image Data Detailed
Radiology Charges
Reports Diagnostic
Text Data CT
Transcribed Image Data MR
Reports Video Ultrasound
Signal Nuclear Med
UBs and Data
Audio Tracing
Itemized Bills Data
Data Pathology
Ultrasound and Images
Cardiac Catheterization
EKG/EEG/Fetal
Examinations Heart Voice Dictations Monitoring Signal
Sounds & Annotations Tracings © 2007

22. 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
© 2007

23. 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
© 2007

24. Electronic Health Records =
Business Records
Subject to Evidentiary Discovery
© 2007

25. Electronic Health Records =
Not Business Records
 Reproductions of the electronic
records that are provided by the
organization to an individual or
another healthcare organization
for convenience purposes
© 2007

26. Electronic Health Records =
Not Business Records
 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
© 2007

27. Electronic Health Records =
Not Business Records
 Personal Health Records (PHRs),
which are patient owned,
managed, and populated -- and
might include copies of the
healthcare organization’s business
record files.
© 2007

28. 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.
© 2007

29. Caveat?
 THE FEDERAL RULES OF CIVIL
PROCEDURE GOVERNING
ELECTRONIC DISCOVERY, effective
December 1, 2006.
For example:
© 2007

30. 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‖.
© 2007

31. 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?
© 2007

32. 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
© 2007

33. Electronic Records Management
 Requires astute decision
making throughout the life
cycle of the electronic record
© 2007

34. 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?
© 2007

35. Electronic Record Life Cycle
 Creating / Receiving
 Indexing
 Searching
 Retrieving
 Processing
 Routing / Distributing
 Storing
 Maintaining
 Securing
 Purging / Archiving / Destroying
© 2007

36. Health
Electronic ^ Records Management
 Example healthcare information
systems capable of creating electronic
records and then processing,
distributing, maintaining, storing,
retrieving, archiving, and destroying
the records…
© 2007

37. Health
Electronic ^ Records Management
 Patient billing and accounts
receivable systems
 Healthcare information systems
 Clinical information systems
© 2007

38. Health
Electronic ^ Records Management
 Cardiology, laboratory, radiology, and
pharmacy information systems
 Picture Archiving and
Communications Systems (PACS)
© 2007

39. Health
Electronic ^ Records Management
 Digital dictation systems and speech
recognition systems
 Word processing (i.e., transcription)
systems
© 2007

40. Health
Electronic ^ Records Management
 Electronic document management
systems (EDMSs)
 Report, print, and output management
systems (e.g., reproduction systems)
© 2007

41. Health
Electronic ^ Records Management
 eMail systems (e.g., Microsoft
Outlook)
 Collaboration systems (e.g., project
extranets and online conferencing
systems)
© 2007

42. Health
Electronic ^ Records Management
 Dynamic Web site systems with online
forms, transactions, and metadata
© 2007

43. Health
Electronic ^ Records Management
 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
© 2007

44. Health
Electronic ^ Records Management
 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
© 2007

45. Health
Electronic ^ Records Management
 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
© 2007

46. 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
© 2007

47. 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
© 2007

48. 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.
© 2007

49. Health
Electronic ^ Records Management
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
© 2007

50. Health
Electronic ^ Records Management
SHORT TERM PLANS
 Develop EHR policy / procedure
guidelines for existing
information systems
 Develop EHR policy / procedure
guidelines before buying new
EHR technologies / systems
© 2007

51. Health
Electronic ^ Records Management
• 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.
© 2007

52. Health
Electronic ^ Records Management
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
© 2007

53. Health
Electronic ^ Records Management
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
© 2007

54. Health
Electronic ^ Records Management
TECHNICAL CONSIDERATIONS
 Destroy unflagged files from the
archive
 Manage large files and file types for
security purposes
© 2007

55. Health
Electronic ^ Records Management
COLLABORATION OF EXPERTS
 Legal professionals
 HIT professionals
 HIM professionals
 Risk / Compliance professionals
 Clinical professionals
© 2007

56. Questions & Answers
dkohn@daksystcons.com
www.daksystemsconsulting.com
© 2007