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EHR Records Risk Assessments
An Evolving Use of the EHR System
Functional Model Standard
HIMSS HL7
April 15, 2015
Reed D. Gelzer, MD, MPH
Co-Chair, HL7 EHR Workgroup
Co-Faciltator, HL7 EHR Records Management
and Evidentiary Support Workgroup
and HL7 EHR/Security Vocabulary Alignment Workgroup
Provider Resources, Inc.
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Overview
EHR-S FM R2: Normative Standard
“The HL7 EHR-S Functional Model defines a
standardized model of the functions that may be
present in EHR Systems.”
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Overview
What is Records Risk?
What does Records Risk look like?
How does the EHR-S FM R2 (aka R2) help?
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Records Risk
Records:
Representations of acts and events in the real world
Risks to their value as accurate representations:
Reliable means of origination
Security
Authenticity
Persistence
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
5
Origination Risk
A group of
inexperienced and
uncertified
inspectors for the
Department of
Licenses and
Inspection conducted
around 600
inspections of unsafe
buildings in a single
week last month, the
Inquirer has learned.
Each of the newly
hired inspectors then
recorded their work
in L&I’s database
under the name of
another man, an
experienced
inspector with the
agency.
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Origination Risk
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Recommendation:
Release of Information (ROI)
Risk Assessment
Evaluating:
1. Authorship
2. Log (“Audit”) functions
3. Amendments
EHR Systems:
Systems of Systems
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Origination For Authenticity
Recommendation:
Release of Information (ROI) Risk Assessment
Examples:
Records releases for business or clinical requests
(legal process or claims support/revenue integrity)
Data extracts to support Quality measures
Transitions of Care Support
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
© 2015 Health Level Seven ® International. All Rights Reserved.
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
R2 Checklist: Originate & Retain
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
R2 Checklist: Originate & Retain
01/01/2011
14
1. The system SHALL provide the ability to capture
(originate) a Record Entry instance corresponding to
an Action instance and context
.
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Checklist: Evidence of Originate
& Retain
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Know Your Objectives
Risk Identification: Keep it simple and practical
Risk Mitigation Mapping
-Training?
-Configuration?
-Design?
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Objectives
Risk Mitigation: Keep it actionable
Medical Staff Bylaws (Hospitals)
Medical Records P&P
EHR FM R2-Derived Due-Diligence
Templates
01/01/2011
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Notables…
HIMSS presentation slides for “Medical-Legal
Cases That Went South” by Dr. Keith Klein
“Electronic Health Records Systems: Testing
The Limits of Digital Records’ Reliability and
Trust” in Ave Maria Law Review, Summer 2014
by Drury, Gelzer, Trites, and Paul.
© 2015 Health Level Seven ® International. All Rights Reserved.
HL7 and Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
