This document discusses legal medical records and information governance. It begins with an overview of electronic health records, legal medical records, and the designated record set. It then covers the legal process of litigation and anticipated litigation, noting the importance of information management. It discusses data and information governance, including developing data management practices. It provides tips for response and preparedness, emphasizing the value of planning over reacting. The summary emphasizes the importance of coordination, collaboration, planning, recognizing potential consequences, and closely connecting legal, privacy and regulatory obligations to relevant information.

1. © 2013© 2013
David Kearney
MS, PMP, CEDS
Legal Medical Record:
Mystery Novel or
Reference Guide?

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Topics Covered
• Legal Medical Record Overview
• Legal Process of Litigation/Anticipated
Litigation
• Data & Information Governance
• Response & Preparedness
• Tips
• Summary

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Legal Medical Record Overview
• Electronic Health Record
• Legal Medical Record
• Designated Record Set
Why?
What is the Difference?

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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

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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

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• 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

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Information Management
Addressed at the Far Left of the
Electronic Discovery Reference Model

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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.

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Data & Information
• Data Growth
• Data Sources
• Information Governance
• Developing Data Management Practices

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Response & Preparedness
• Why
• How
• Results
Proactive vs. Reactive
Planning vs. Panic

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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

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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

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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

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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/