In addition to its essential role in clinical care, the medical record is the healthcare organization's most important business and legal record. Defining this legal record in a predominantly paper environment is a fairly straightforward task.
But what's the definition of the legal medical record in today's increasingly electronic environment? What are the legal contents of transitional hybrid records that are part paper, part electronic?
Historically, guidelines for what constitutes the legal record are the organization's prerogative so long as state law, accrediting standards, and Medicare and Medicaid conditions of participation are met. It is clear what information will be released when authorizations and subpoenas are received. When a record is admitted into court, the health information manager is able to attest to how the record was created and maintained and can demonstrate that a complete record has been turned over.
Today, a patient's electronic health record consists of data files that may be logically linked, but not physically linked, and which may consist of different data types, formats and media. For example, an EHR may be a combination of files from the laboratory, pharmacy, picture-archiving and communications systems, cardiology, results reporting systems, computerized physician order-entry systems, nursing-care planning systems and transcription systems. Some may also store structured clinical and administrative data in a clinical data repository.
The multimedia EHR challenges the boundaries of the medical record as we have known it. Are audio files of dictation and telephone consultations part of the legal record? What about videos of procedures and telemedicine consultations?
Healthcare organizations are doing their best to develop internal policies for what constitutes a legal record as they transition to electronic records. But too often state laws and legal preferences tether them to regulations designed for a paper-based system, and current e-records management standards and software are not yet robust enough to create a sound legal record from the more transactional types of information contained in an EHR.
Regardless of its format, the health record must meet the requirements of the legal and business record for the organization. It must document and validate the care process and its results. It must capture indications for treatment and services provided. It must be the basis for communication among providers and for billing and reimbursement, legal adjudication, research and many other uses.
Legal health records must also conform to federal regulation, state laws and voluntary accreditation standards, but these requirements are often conflicting. There is no agreed-upon definition of the legal health record across the U.S., and this has a number of important consequences. As healthcare organizations each craft their own policies for what constitutes a legal EHR, this lack of uniformity will impede interoperability in a national health information network and perpetuate administrative complexity. It also makes the system more vulnerable to fraud.
In a new report, a cross-industry committee of senior-level executives from both the private and public sectors lists "the adoption of a standard minimum definition of a legal health record" as one of its 10 guiding principles to strengthen the fraud-management capability of a nationwide, interoperable health IT infrastructure.
As we move toward an interoperable health information network, the definition and standards for a legal record must become more uniform. The American Health Information Management Association recently published guidance for healthcare organizations regarding hybrid and fully electronic health records. The advice addresses the data content of the legal record and how to navigate challenges unique to the electronic environment, such as handling alerts and reminders, continuity-of-care records and information provided by patients.
But there is much more work to be done. Adopting a national definition for the legal health record and defining a minimal content standard must be on the work plan for the American Health Information Community as it guides development of the national health data network. Laws, regulations and voluntary standards need to be consistent, and EHR software must conform to a minimum standard.