Ms. Nelson, speaking at AHIMA’s 2011 Legal EHR Summit in Chicago on Aug. 15, gave five considerations a hospital should think about in case a deposition is issued.
1. Define your “legal EHR.” Ms. Nelson explained that for most hospitals who have already implemented their EHRs, this has already been done. However, she said hospitals that are just starting to embark on EHR implementation need to have the legal scope of their EHR written in case health records are admitted into legal proceedings.
2. Master Patient Index match. For paper records, Ms. Nelson said the MPI always matches the paper record because everything was handwritten on the spot with no hidden changes. However, EHRs can sometimes confuse data between patients, and she said the MPI must always match the record in question.
3. Ownership. This is where things can get dicey, Ms. Nelson said. Who truly owns the EHR? For example, does a radiology group claim ownership because it created the report, or does a physician own it because he or she read the report? Because EHRs move seamlessly throughout the system, ownership of the records must be figured out.
4. Policies for documentation. Health information managers must manage EHRs, and if done according to the following policies, it could lead to a smoother deposition, Ms. Nelson said.
• Entries documented in the normal course of business.
• Entries kept in the regular course of business.
• Entries made at or near the time of the event in question.
• Entries made by the person(s) within the business with knowledge of the acts, events, conditions, opinions, or diagnoses appearing in it.
5. Standard questions. Similar to policies for documentation, a health information manager should understand all standard deposition questions, including questions about his or her role within the organization and whether or not the records have been altered.
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