E-Discovery Toolkit: Prepare or Beware

If your organization doesn’t have a procedure for responding to e-discovery requests, or for defining the legal health record, the HIM department should get the ball rolling or it will never happen, advised e-discovery expert Diane Premeau, MBA, RHIA, CHP, CHC, on Monday at AHIMA’s Health Information Integrity Summit in Alexandria, VA.

In her “Source System Review: A Toolkit for Finding Your Legal Health Record for E-Discovery,” Premeau, director of HIM at Daughters of Charity Health System, O’Connor Hospital, in San Jose, CA, gave privacy officers, compliance professionals, and system users a practical guide to implementing e-discovery procedures and processes in their departments and facilities.

The first step, according to Premeau, is defining e-discovery, defining the legal health record, and then deciding who is the steward of the legal health record.

Premeau defined e-discovery as “the process of preparing electronically managed information as requested for legal discovery in healthcare proceedings.” Meanwhile, the definition of legal health record Premeau used included “information created or received or maintained by an organization that is the business record of activities, operations that support decisions made in patient care, supports claims for revenue, serves as legal testimony regarding illness, injury, response to treatment, and caregiver decisions. All of which is generated for healthcare and released upon request.”

When Premeau first started this process on her own, she created a “Record Matrix” to help define the location of a health record from creation to storage. The Record Matrix is helpful because so many departments are deploying systems and may not consult with HIM for document requirements.

Next Premeau outlined the steps to complete a Source System Review, which involves making appointments with each system administrator to verify the integrity of all incoming data. Premeau says it’s critical to meet with system administrators within the facility and with vendors, and to ask them to describe their processes in their own words.

“This will give you a good idea of how well they would support the system in an e-discovery interrogation,” Premeau said.

 

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Follow the Journal‘s coverage for news and insights from AHIMA’s Health Information Integrity Summit taking place September 16-17 in Alexandria, VA. To explore more, click here.

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