AHIMA 2013 Presentation - LHR/LMR

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AHIMA 2013 Presentation - LHR/LMR

  1. 1. © 2013© 2013 David Kearney MS, PMP, CEDS Legal Medical Record: Mystery Novel or Reference Guide?
  2. 2. © 2013 Topics Covered • Legal Medical Record Overview • Legal Process of Litigation/Anticipated Litigation • Data & Information Governance • Response & Preparedness • Tips • Summary
  3. 3. © 2013 Legal Medical Record Overview • Electronic Health Record • Legal Medical Record • Designated Record Set Why? What is the Difference?
  4. 4. © 2013 Legal Medical Record • “generated at or for a healthcare organization as its business record and is the record that would be released upon request” American Health Information Management Association (AHIMA) • Each organization must identify the content required for its own legal medical record as well as the standard for maintaining the integrity of the content
  5. 5. © 2013 Electronic Health Record • Document at Point of Care • No concept of completeness • For Clinical decision support • Focus – present/near future • Contains Discrete data (data centric) • On-going • Authentication on entry • Continually modifiable • Not designed to distribute • Some tracking Legal Medical Record • May Document Post Delivery of Care • Concept of Completeness • For Justification/analysis • Focus – past • Contains Documents/Pictures (document centric) • Episodic • Authenticated by signature • Unalterable • Produce consistently • HIPAA “trackable” EHR vs LMR
  6. 6. © 2013 • EDRM Overview - Info Management is Key • Includes Electronic and Paper Records (Evidence) • Process of Evidence • Preservation • Consistency of Process • Value of Data/Risks of Data • Penalties • Reasonableness Legal Process of Litigation/Anticipated Litigation
  7. 7. © 2013 Information Management Addressed at the Far Left of the Electronic Discovery Reference Model
  8. 8. © 2013 Information Management “Part of the reason eDiscovery is so expensive is because companies have so much data that serves no business need. … Companies are going to realize that it’s important to get their information governance under control to get rid of the data that has no business need … in ways that will improve the company's bottom line…” — U.S. Magistrate Judge Andrew J. Peck, CGOC Faculty Member, in a video interview courtesy of JD Supra Law News, February 4, 2013.
  9. 9. © 2013 Data & Information • Data Growth • Data Sources • Information Governance • Developing Data Management Practices
  10. 10. © 2013 Response & Preparedness • Why • How • Results Proactive vs. Reactive Planning vs. Panic
  11. 11. © 2013 Tips • Assemble Team • Know Where Your Data Is • Assess Risks – Legal Dept. – Business needs – Legal holds – Regulatory obligations • Develop Plan - Collaboration • Document Plan • Implement Plan • Follow Plan – Consistency is Key – Not following a plan is worse in some instances than not having a plan at all • Audit Plan – Verify compliance regularly • Revisit Standards, Regulations, Laws
  12. 12. © 2013 Summary • Coordination & Collaboration • Plan First • Recognize Potential Consequences • Connect legal, privacy and regulatory retention obligations directly to relevant information. • Work closely with each other… – Counsel with Technology Groups – HIM with Counsel – C-Level with HIM – Inside Counsel with Outside Counsel and vice- versa
  13. 13. © 2013 In Practice… • Context of a Matter/Event • Internal Policy • Demonstrated Compliance/Consistency • Data Maps • Preservation & Collection • Data Chain of Custody • Data Review by Counsel/Legal Team
  14. 14. © 2013 Thank You Don't be caught trying to extinguish a fire when fire prevention was really the answer David Kearney MS, PMP, CEDS www.linkedin.com/in/davidjkearney/

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