During a networking breakfast about the legal EHR at the AHIMA 2006 Convention in Denver last week, faculty discussed several ideas related to the topic.
“A greater comfort level and less fear of technology is important to furthering electronic records,” said Keith Olenik of The Olenik Consulting Group in Kansas City, Mo. Facilities also need to define their legal record so that they can defend it, he said. HIM professionals have “had a hard time getting their organization to understand that the electronic health record isn’t the legal record -- it’s a subset.”
The risks associated with not having a demonstrably valid record are immeasurable, said Reed Gelzer, MD, chief operating officer for Advocates for Documentation Integrity and Compliance, headquartered in Revere, Mass. Those risks include billing inaccuracies and malpractice allegations.
Valid electronic records require authenticated documentation, so organizations “must define authentication,” said Katherine Lusk, director of HIM at Children’s Medical Center of Dallas. “If we focus on the fundamentals, we will have a strong foundation. We’re being swayed because other people are becoming interested in the HIM profession.”
The scope of the legal health record is expanding, said Cheryl Servais, vice president of compliance and privacy officer for Precyse Solutions in Wayne, Penn. That will force facilities to reconsider whether such items as billing records and images from PACS are part of the legal record. And more and more patients are keeping a personal health record. “Can patients authenticate their own records?” she queried.