The healthcare standards development organization Health Level Seven has released for public comment prior to balloting what it is calling the Legal Electronic Health Record System Functional Profile, a guide that can help an organization maintain an EHR for legal and business purposes, as well as reduce costs and inefficiencies, according to an HL7 news statement.
The profile is based on an earlier work by HL7, its EHR System Functional Model Standard, and is a subset of requirements to assure data quality and integrity for all purposes and end-uses of healthcare data, according to HL7. Because legal validity is at stake for all uses of electronic records as admissible business records, including admissibility as medical records, the legal EHR is of primary importance to healthcare operations and to interoperability, the statement said.
The profile was made available Monday for a 30-day public comment period and could be balloted by an HL7 committee later this year.
Don Mon is vice president of practice leadership for the Chicago-based, not-for-profit American Health Information Management Association and has served as co-chairman of the EHR Technical Committee at HL7. In the statement, Mon said the EHR legal profile leaves the process of identifying the content for the legal record to care-setting-specific profiles in order to account for their individual needs and requirements.
The legal profile follows the April release by HL7 of the Emergency Care Functional Profile, the first clinical-care EHR profile in what will likely be a series of profiles to be developed under the HL7 EHR System Functional Model Standard. Work is under way on additional profiles for long-term-care facilities, behavioral health, general child care and regulated clinical research.
Mark Leavitt, chairman of the federally supported Certification Commission on Health Information Technology, said HL7 draft standards on electronic health records were used by CCHIT as a guide in creating its testing and certification criteria. More than 80 EHR systems have been certified by CCHIT for ambulatory care.
We used the functional model as a starting point, Leavitt said. We added our own wisdom to it, but it was the start.
Going forward, Leavitt said the EHR legal profile will become a part of future CCHIT criteria deliberations, Leavitt said.
We just restructured our work groups and we actually have a work group called the privacy and compliance panel. This is very relevant for that work group.
The current CCHIT criteria already includes certain elements of a legal record, including a requirement that systems have the capability to prepare an audit of who has accessed the medical record and the ability to lock the record once it is created, not allowing an alteration of the record without leaving a record of the alteration, Leavitt said.
But we want to take a look at it (the HL7 legal profile) and supply that to the privacy and security expert panel and see if they want to make any recommendations for 2008 (CCHIT) criteria, he said.
What do you think? Write us with your comments at [email protected]. Please include your name, title and hometown.