As more patient records become automated and provider organizations increasingly are working in a hybrid environment of paper and electronic records, the rules of the game for establishing and maintaining a legal medical record are getting blurry.
“The challenges of hybrid records create new relationships and dependencies,” says Suzanne Layne, corporate director of health information services at four-hospital Main Line Health System in Bryn Mawr, Pa.
Layne will speak of how the rules of health information management are changing and how Main Line is handling the challenges during an educational session at HIMSS13 in New Orleans. The confusion will just get worse as EHR projects result in enterprise legal records supporting continuity of care in addition to the legal record in a hospital, and health information exchange between organizations becomes common. There will be a lot of downstream policy and legal tentacles, she adds. For instance, regarding adoption and child custody cases, who is authorized to see what health information?
Here’s another example of how responsibility for the legal medical record is changing: Let’s say your hospital’s legal record on a patient notes that she has a history of breast cancer, when it should say she has a family history of breast cancer. In the emerging era of health information exchange, what is the hospital’s obligation to track and correct erroneous records sent elsewhere? What is an HIE organization’s obligation to correct records it has received from elsewhere?
There are still a lot of precedents to be set, and everyone is still learning during the process of increased electronic records and connectivity, Layne says. Her message: “New challenges will arise and the complexities will continue to present themselves.”
Education session 50, “Legal Medical Record: Mystery Novel or Reference Guide?” is scheduled at 12:15 p.m. on March 4 in Room 282.
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