Medical records, whether paper-based or electronic, must also meet the requirements of a legal health record, and the September issue of the Journal of the American Health Information Management Association offers guidelines for achieving that objective. Legal health records are used to show documentation to third parties, record the basis for a healthcare decision, support requests for reimbursement from third-party payers or serve as legal testimony.
The report, the product of a 21-person AHIMA work group, states that there is no one-size-fits-all definition for a legal health record. Typically, however, it contains anything that will be disclosed upon request. To that end, the first step in creating a legal health record is to determine which legal organizations interact with a medical practice and what information they need to carry out their regulatory, financial or accrediting functions, the report states. The report listed 48 items -- from advance directives to ECG waveforms -- that could be included in a legal health record.
Separately, Arizona Gov. Janet Napolitano signed an executive order Aug. 31 creating the Arizona Health-e Connection, a 39-member board charged with developing a plan to build the state's healthcare information technology infrastructure. Over the next six months, the panel will work to ensure patient privacy and identify possible funding sources.
"An interoperable electronic health system will improve the quality and reduce the cost of healthcare in Arizona," Napolitano said in a statement. She added that her goal is to get widespread adoption of EMRs by 2010, four years earlier than the federal goal set by President Bush.
Appointments to a similar panel were announced Aug. 22 by Kentucky Gov. Ernie Fletcher, M.D. The Kentucky e-Health Network Board was created by state legislation signed into law on March 8 by Fletcher. Its purpose is to develop a secure statewide electronic network to access and transfer healthcare information.