Electronic health records (EHR) systems must be supported by specific functionality to properly maintain business records in the support of regulatory, payment, and litigation compliance, according to Michelle Dougherty and Rita A. Scichilone, of the American Health Information Management Association. Dougherty and Scichilone, provided advice to compliance officers and professionals on critical issues that need to be addressed for a “compliant EHR” system at a seminar sponsored by the Health Care Compliance Association.
Compliant EHR systems. Compliance professionals play an important role in the EHR system selection process. The burden is on the purchaser and the user of these tools to assure that in actual use the EHR system chosen qualifies as a legal record. Regardless of the format - paper, hybrid, or fully electronic - a record must meet the requirements of the official legal record for the organization. Health care entities and vendors sometimes neglect to build in the record management processes and system capabilities needed to ensure the electronic rather than the paper version can stand as the legal business record. Information in an EHR system that does not qualify as a medical record, becomes hearsay, not a bona fide record, and its integrity for any and all uses becomes suspect. This “legal EHR” is a subset of content within the EHR system.
Both manual and electronic medical record systems should maintain a medical record for each patient; properly file and retain each record to ensure prompt retrieval; and be accessible to authorized users, and protected from loss, destruction, alteration, reproduction, or theft.
Risks and concerns. Not addressing legal and compliance needs may result in: (1) challenges to documentation that supports billing, (2) potential increase in litigation costs, and (3) potentially higher settlements. Compliance professionals must be aware of gaps in the maintenance of these legal EHR systems, especially in metadata. Limited, inaccessible metadata tools result in event logs that may not be available at reasonable cost or at all. Records potentially may be overwritten because of missing data elements essential for proper record keeping.
CCH Chicago Bureau, Aug. 12, 2008
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