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What HIM Leaders Should Know about the Legal Health Record

Carl Cottrell, for HealthLeaders Media, January 5, 2010

As we concentrate our attention on the pressing challenges of extending into qualified electronic health records, complying with the HITECH Act, and achieving "meaningful use," we dare not forget our old friend, the legal health record. No matter what we do on the EHR front, we must still maintain a LHR, we must assure its conformance to standards of content, accuracy and completeness; we must keep it for decades and guarantee its integrity; we must be able to produce copies of it on demand. Further, the LHR is an essential component of the revenue cycle serving as both the source of coding and the documentation that must be provided to support billing. The LHR is neither unrelated to the EHR nor is it completely included, it is separate but related, and has different objectives and users. As we will see, applying automation to the LHR gets us much closer to meaningful use.

The LHR is, in essence, the hospital's "flight recorder." The flight recorder is not used to fly the aircraft, its job is to provide an indisputable history of the flight. These are the same functions performed by the LHR.

The EHR, on the other hand, is like the aircraft pilot's tools, controls, warnings, navigation displays, communications, and so on. In healthcare, some of these tools take the form of CPOE, clinical decision support, vital signs, e-prescribing, and results reporting. These tools should evolve rapidly and be replaced as they become obsolete or feature constrained much like aircraft systems. This very need is antithetical to the long term retention requirements of the LHR. As EHRs are relatively new, few have yet found themselves in the uncomfortable position of being unable to respond to a subpoena because a portion of the historical record was within a transcription or lab system that was no longer available. Data in the "flight recorder" endures. The LHR, like the flight recorder, must be physically or virtually distinct to ensure it endures over time as clinical systems evolve.

Other major differences between the needs of EHRs and the needs of LHRs concerns their intended audiences, the presentation of information, the form of data exchange and the requirements of HIPAA for privacy and tracking of access. The intended audience of EHRs is clinicians, the data presentation is fluid and graphical, data is designed to be viewed on electronic media and record accesses and updates are tracked to the user level. In a LHR, the intended audiences are external to the patient care process, the data presentation is fixed and delimited by an occasion of service, data is presented on paper reports and the recipient of the information must be logged in addition to the user sending the information. An EHR designed around LHR needs makes a terrible EHR and vice versa.

The EHR automates and streamlines the clinician's workflow. The results to be achieved are better patient care and better utilization of resources. The users of the EHR are primarily clinicians and the improvement theory is that electronic workflows, rules and information access are more efficient and effective than paper based processes. This same theory can also be applied to the LHR, many of which today are partially or completely based upon paper.

The workflows to be streamlined and automated by eliminating the paper in the LHR are mainly administrative as opposed to clinical and the potential for improvement is profound—on the order of $10,000 per adjusted occupied bed per year if all revenue cycle gains are included. To appreciate the source of these gains one need only examine the typical LHR workflows.

If you look only at physical movement—movement of the chart to various areas and movement of people traveling to HIM to access the chart. The source of waste in paper or hybrid processes is that the chart can only be in one place at a time. If it is in the completion area waiting for a physician to sign a document, it is not available to a coder, and vice versa. Processes that affect the revenue cycle must wait for those which don't. Delayed time negatively impacts billing and collections, and trying to accelerate the process without the appropriate chart information negatively impacts case mix and denial rates. Further, virtually all of the movement is choreographed manually, automation of the tasks that must be completed in each of these areas is mostly impossible. These two traits of paper and hybrid LHRs—sequential access and manual workflows—waste time, space, effort and money.

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