EHRs as the Business and Legal Records of Healthcare Organizations (2010 update)

This practice brief has been updated. See the latest version here. This version is made available for historical purposes only.

Editor's note: This update combines and supplants the October 2004 practice brief "The Strategic Importance of Electronic Health Records Management" and the June 2005 practice brief "A Checklist for Assessing HIM Department Readiness and Planning for the EHR."

More than ever, the healthcare industry is making significant progress in the quest for electronic health records (EHRs), which are believed will improve the quality and safety of patient care and achieve real efficiencies in the healthcare delivery system. EHRs are essential to better clinical integration and health information exchange. Accordingly, emphasis has been placed on the clinical aspects of EHRs that support the patient care process and decision making.

Well-designed EHR systems will:

• Improve the quality of care by enabling automated collection of data that support quality measurement and reporting;
• Increase operational efficiency and contain costs by streamlining clinical workflow and avoiding duplicate procedures;
• Collect data for secondary uses, such as clinical research, population and public health reporting, and fraud detection and deterrence; and
• Serve as the foundation for health information exchange.

However, from a strategic standpoint, it is important to look beyond the immediate clinical uses of the information and develop a plan that ensures that the EHR and EHR system can support the healthcare organization's business and legal needs as well. The use of the EHR for business and legal purposes is every bit as mission critical as its clinical uses and must be reflected in approaches to its management. However, in today's urgency to begin deploying EHRs, healthcare entities, vendors, and others sometimes neglect to build in the processes and system capabilities needed to enable optimal EHR management functions and ensure the electronic rather than the paper version can stand as the legal business record.

The Health Level Seven EHR Records Management and Evidentiary Support (RM-ES) Project EHR Functional Profile supplies conformance criteria that support records management functionality and enable the EHR to be used as the legal business record of the healthcare enterprise. The profile identifies the key infrastructure functions that support the management of health records within the system for business and evidentiary purposes.¹

Definition of EHR Management

EHR management (EHRM) is the process by which digital health information is created or received and preserved for evidentiary (e.g., legal or business) purposes. 

EHRM requires planning and decision making for the entire life cycle of the information contained in EHR systems?from creation or capture, review, modification, and sharing through searching, tracking, preserving, retention, and, ultimately, destruction of the information that has been designated as health records of the organization or entity.

Decision making includes, but is not limited to, which information to declare as the record of care (or identifying the legal health record), the assignments of authorities and responsibilities, the design and administration of the processes to ensure integrity, and the audit and review of the performance of those processes. Healthcare organizations must make critical decisions about the role and use of analog storage media, such as paper and film, in the early phases of EHR system development to avoid the dilemma of maintaining dual systems.

HIM Roles and Responsibilities in EHRM

HIM professionals must be involved with the adoption and implementations of EHRs and have the professional responsibility to guide these efforts to ensure that the EHR meets the functional requirements for a health record that can be used for business and legal purposes.

To guide HIM professionals, AHIMA's e-HIM leadership models are aimed at developing a comprehensive framework and suite of tools that includes:

• Assuming a leadership role to establish organizational standards for EHR systems that constitute the record of care to ensure that such records meet legal and business requirements
• Establishment of policies and procedures for creating and maintaining the integrity of the legal health record throughout its information life cycle
• Identification of resources required to manage EHRs and systems, including required budget, staffing, technology, and processes
• Communication, education, and, when required, training regarding EHRM for users of the EHR
• Fostering stewardship among custodians of the technology and systems that constitute the EHR
• Development and implementation of audit, review, and other control processes that support the integrity of EHRs, enabling them to meet the business and legal needs of the healthcare organization

HIM professionals must take the lead in establishing organization-wide principles for electronic patient records and clinical documentation applications. Organizations must establish policies that identify the content that constitutes the legal record and ensure that health records meet regulatory requirements. They must educate staff on the practices and procedures that maintain record integrity.

As the traditional custodians of the paper medical record and medical record system, HIM professionals are trained to ensure the quality, privacy, and integrity of the EHR. Today, the EHR can and often does reside in several different information systems. HIM professionals ensure that information management and record of care standards are applied consistently across these various systems to maintain the level of integrity necessary for the healthcare organization's records.

HIM professionals long have been translators of clinical data for their business and financial offices using their expertise, understanding of documentation, and coding functions. Now is the time for them to share with healthcare consumers their knowledge as data translators. The shift to a consumer-centric model requires HIM practitioners educate and assist consumers in accessing secure patient information and translating medical terminology across the continuum of care and in advanced technologies.

The electronic environment requires HIM professionals manage data and assist in the development of decision-support systems for individual, aggregate, and public health data. HIM practitioners have a tremendous responsibility to provide the support for organizational, local, and national systems that ensure quality, integrity, and availability of healthcare data. The role of the public health officer in providing strategic leadership for health information in the public health sector has been gaining importance. In fact these activities are already under way and can be supported fully by the EHR.

The EHR is changing the approach to managing health information. One of the many important roles in this transition that HIM practitioners must play is to provide leadership in ensuring that healthcare organizations are able to use the information generated by EHRs for legal and business purposes. Healthcare organizations must implement EHR systems that meet the requirements of a legal business record. HIM departments may reference appendix B, "Checklist for Transition to the EHR," in preparation for going paperless.

Notes

¹HL7 EHR Technical Committee. "Chapter Five: Information Infrastructure Functions." Electronic Health Record-System Functional Model, Release 1 (February 2007).

Additional Material

Although this practice brief provides an overview of the importance of strategic electronic document management, much supporting information is necessary to make a successful transition to the EHR. These considerations are included in appendix A of this practice brief, "Issues in Electronic Health Record Management."

References

AHIMA. "A Vision of the e-HIM Future: A Report from the AHIMA e-HIM Task Force." 2003. Available online in the AHIMA Body of Knowledge at www.ahima.org.. 
 
"HIM Professionals Vital in Transition to e-HIM." AHIMA Advantage 7, no. 6 (2003): 1, 3?4. 

Prepared by

Beth Acker, RHIA
Cecilia Backman, MBA, RHIA, CPHQ
Sara Briseno, RHIT
Camille Cunningham-West, RHIA
Cathy Flite, MEd, RHIA
Deborah Kohn, MPH, RHIA, FACHE, CPHIMS 
Beth Liette, RHIA
Cindy Loranger
Nicole Miller, RHIA
Diana Warner, MS, RHIA, CHPS

Acknowledgments

Mary Ellen Mahoney, MS, RHIA
Donna J. Rugg, RHIT, CCS
Allison F. Viola, MBA, RHIA
Lydia Washington, MS, RHIA, CPHIMS
Lou Ann Wiedemann, MS, RHIA, CPEHR

Prepared by (original)

Beth Acker, RHIA 
Debra Adams, RN, RHIA, CCS, CIC 
Camille Cunningham-West, RHIA 
Michelle Dougherty, RHIA, CHP 
Chris Elliott, MS, RHIA 
Cathy Flite, MEd, RHIA 
Maryanne Fox, RHIA 
Ronna Gross, RHIA 
Susan P. Hanson, MBA, RHIA, FAHIMA 
Deborah Kohn, MPH, RHIA, FACHE, CPHIMS 
Tricia Langenfelder, RHIA 
Beth Liette, RHIA 
Mary Ellen Mahoney, MS, RHIA 
Carol Ann Quinsey, RHIA, CHPS 
Donna J. Rugg, RHIT, CCS 
Cheryl Servais, MPH, RHIA 
Mary Staub, RHIA, CHP 
Anne Tegen, MHA, RHIA, HRM 
Lydia Washington, MS, RHIA, CPHIMS 
Kathy Wrazidlo, RHIA

Acknowledgments (original)

Darice Grzybowski, MA, RHIA, FAHIMA
Kelly McLendon, RHIA

The original AHIMA Electronic Health Records Management work group was funded by a grant to the Foundation of Research and Education (FORE) from Precyse Solutions.