AHIMA 2013 Presentation - LHR/LMR

Santé & Médecine Business

© 2013
Topics Covered
• Legal Medical Record Overview
• Legal Process of Litigation/Anticipated
Litigation
• Data & Information Governance
• Response & Preparedness
• Tips
• Summary

© 2013
Legal Medical Record Overview
• Electronic Health Record
• Legal Medical Record
• Designated Record Set
Why?
What is the Difference?

© 2013
Legal Medical Record
• “generated at or for a healthcare
organization as its business record and is the
record that would be released upon
request”
American Health Information Management Association (AHIMA)
• Each organization must identify the content
required for its own legal medical record as
well as the standard for maintaining the
integrity of the content

© 2013
Electronic Health Record
• Document at Point of Care
• No concept of completeness
• For Clinical decision support
• Focus – present/near future
• Contains Discrete data (data
centric)
• On-going
• Authentication on entry
• Continually modifiable
• Not designed to distribute
• Some tracking
Legal Medical Record
• May Document Post Delivery of
Care
• Concept of Completeness
• For Justification/analysis
• Focus – past
• Contains Documents/Pictures
(document centric)
• Episodic
• Authenticated by signature
• Unalterable
• Produce consistently
• HIPAA “trackable”
EHR vs LMR

© 2013
• EDRM Overview - Info Management is Key
• Includes Electronic and Paper Records (Evidence)
• Process of Evidence
• Preservation
• Consistency of Process
• Value of Data/Risks of Data
• Penalties
• Reasonableness
Legal Process of
Litigation/Anticipated Litigation

© 2013
Information Management
Addressed at the Far Left of the
Electronic Discovery Reference Model

© 2013
Information Management
“Part of the reason eDiscovery is so expensive is
because companies have so much data that serves no
business need. … Companies are going to realize that
it’s important to get their information governance
under control to get rid of the data that has no
business need … in ways that will improve the
company's bottom line…” — U.S. Magistrate Judge
Andrew J. Peck, CGOC Faculty Member, in a video
interview courtesy of JD Supra Law News, February 4,
2013.

© 2013
Data & Information
• Data Growth
• Data Sources
• Information Governance
• Developing Data Management Practices

© 2013
Response & Preparedness
• Why
• How
• Results
Proactive vs. Reactive
Planning vs. Panic

© 2013
Tips
• Assemble Team
• Know Where Your Data Is
• Assess Risks – Legal Dept.
– Business needs
– Legal holds
– Regulatory obligations
• Develop Plan - Collaboration
• Document Plan
• Implement Plan
• Follow Plan – Consistency is Key – Not following a plan is
worse in some instances than not having a plan at all
• Audit Plan – Verify compliance regularly
• Revisit Standards, Regulations, Laws

© 2013
Summary
• Coordination & Collaboration
• Plan First
• Recognize Potential Consequences
• Connect legal, privacy and regulatory retention
obligations directly to relevant information.
• Work closely with each other…
– Counsel with Technology Groups
– HIM with Counsel
– C-Level with HIM
– Inside Counsel with Outside Counsel and vice-
versa

© 2013
In Practice…
• Context of a Matter/Event
• Internal Policy
• Demonstrated Compliance/Consistency
• Data Maps
• Preservation & Collection
• Data Chain of Custody
• Data Review by Counsel/Legal Team

© 2013
Thank You
Don't be caught trying to extinguish a fire
when fire prevention was really the answer
David Kearney
MS, PMP, CEDS
www.linkedin.com/in/davidjkearney/

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