The challenge of producing one completed and defensible legal medical record from a hybrid of paper and electronic record-keeping systems has been a recurring theme for the American Health Information Management Association. Not surprisingly, it was a topic of discussion at AHIMA's 81st annual convention in Grapevine, Texas, Monday.
Debi Nelson, director of information management and privacy officer for Trinity Health, Minot, N.D., drew hundreds of conferees to her session, “Are You on Track with Your Legal EHR?”
Since new trial rules of discovery are now in play, it is important for healthcare organizations to redefine in writing what a legal e-health record means. Nelson's counsel was for health information management professionals to be proactive in getting started, but insist on a collaborative process within their healthcare organizations in creating the new definition by forming a legal EHR committee.
Keep in mind, Nelson said, that what a clinician might see in daily practice using an EHR as a record-creating and -retrieval device most likely will not be the record system they'll need to reference, review and defend in court, should a legal issue arise.
Nelson recounted the preparation of a physician witness the day before the doctor was to appear and be questioned by opposing legal counsel at a deposition. The physician used an EHR to create the record of the patient involved in the litigation, but the legal record the hospital was going to present in the deposition was on paper.
“You define your legal medical record as what you print,” Nelson said, but the physician, used to seeing the record on a computer screen, looked over the paper record and said, “I've never seen that before in my life. She just kept saying, throughout her entire deposition, ‘But it was on the screen.' ”
Nelson said it is “just pretty horrifying” for a physician being sued to see something so unfamiliar. The key is advance preparation. “When they talk about that blue doohickey, or that little squiggle, there is not much you can do 24 hours before a deposition. So, be involved with your attorney early.”
“As long as you are correctly prepared and you have your document in hand, we can have hope that our electronic home will become more comfortable as we settle into our new surroundings,” Nelson said.
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