Posted on Aug. 25, 2008

"What's the difference between a lawyer and a vulture? Frequent flier miles."

"Have you heard about the special 'lawyer's word processor'? No matter what font you select, everything comes out in fine print."

"Why won't sharks attack lawyers? Professional courtesy."

For whatever reason, lawyer --and all thing legal, for that matter--have generated enough contempt to create one of the largest pools of jokes in the English language. In some cases, people's personal courtroom experiences have fueled their feelings. But many times, to the majority of people, it just seems like the legal profession makes things more difficult. All of that crossing your "T's" and dotting your "I's"--is it really necessary? Are the many legal rules, regulations and loopholes just to drive us crazy, or do they serve some all-important purpose?

This feeling of frustration is understandable for those defining a legal medical record--especially in a hybrid environment. In a time when health information is maintained in an array of different formats and systems, the legal medical record has become even more complex. Many health care providers struggle to define their legal health record while being mindful of the HIPAA privacy requirement for a designated record set. Add to these elements the fact that extensive metadata is often linked to electronic records, and you're looking at quite a challenge.

This month, our panelists discuss how they've worked to define their legal medical record in a hybrid environment, highlighting their challenges as well as what worked for their organization.

Brandwein: How have you worked with your medical records department to ensure that during the transition from paper to electronic, a proper legal medical record is maintained?    

Glennda Gore, RHIA, vice president, corporate compliance and risk management; former HIM director, McAlester (OK) Regional Health Center: We've defined the legal medical record through our medical records committee and trained our staff on not only the definition, but how that definition actually translates to their activities and duties. In other words, we gave them specific examples to "bring it to life" in real situations.

For instance, when a patient walks into the HIS department and wants copies of his or her medical record for another doctor, we've instructed our staff on the importance of retrieving that copy for the legal medical record--not just pulling it up from the EMR. By giving the team members practical situations that they'd encounter on a daily basis, we made the legal medical record more comprehensible and less abstract.

Beth Kost-Woodrow, RHIA, chief privacy officer and executive director, WellStar Health System, Atlanta, GA: Our HIM directors did something very difficult and very impressive. After a pre-determined date, they didn't release paper records unless it was absolutely critical to the patient's care. So many people were reluctant to use our EMR, and they constantly criticized the HIM directors for holding fast to this policy. The pay-off, though, was the assurance that we maintained integrity of our legal medical records. Think about what happens if you aren't strict with this policy: Let's say you give someone a paper record and it's already scanned. If they make a paper note, your integrity is compromised. It wasn't easy to stick to our guns, but it really helped us sleep at night.

Brandwein: Defining your legal medical record is a highly collaborative effort. Who were the key players that worked to maintain the legal medical record, and how often did you communicate?

Kost: Our team included the legal department, HIM managers and transcription managers, as they were the key stakeholders who could best define our legal medical record. We had four or five meetings over the course of a year, and that helped us progress in parallel with our hospital's efforts to become e-enabled.

Gore: We mainly worked with our legal counsel; they were the ones that kept tabs on what our state law defined as a legal medical record. With their input, I was responsible for writing the policy, and then I sent it to our medical records committee for approval.

Brandwein: What surprises or challenges did you encounter when defining and maintaining the legal record?

Kost: An obvious challenge is the fact that the industry hasn't created a clear, black-and-white definition of the legal medical record. And there are dangers in not having a standard. There are controversies around items such as date/time stamps and the metadata behind patient data in IT systems. Is metadata part of the legal record? Are date/time stamps? These questions weren't even an issue in the paper world. Now, you just have to draw a line in the sand, make decisions and stick to them. It'd be so nice, though, to have a consistent law or regulation that would provide definition and standards. That way, all health care providers would be following the same standards--and that would  help us down the road, as we move closer to interoperability.

Meanwhile, as health care organizations strive to define and maintain legal records in a hybrid environment, organizations such as the American Health Information Management Association have wonderful resources and discussion groups to provide help and guidance. Stay tuned for next month's column, as we discuss the evolving relationship between HIM and IT--and how the hybrid world has changed it.

Aaron Brandwein s divisional vice president for HealthPort, formerly SDS. He is responsible for HealthPort's EDMS technology division and currently serves on the AHIMA Exhibit Advisory Committee and has spoken at numerous AHIMA national and state conferences on the topic of electronic and hybrid records.