Policies & Procedures
As exemplified by the American Health Information Management Association (AHIMA), their mission is "to improve healthcare by advancing best practices and standards for health information management and the trusted source for education, research, and professional credentialing." The impact of AHIMA on EHR results in an EHR and EHR system maintaining a high level of integrity for business and legal purposes.
All in all, a health organization or practice is responsible for creating policies and procedures that govern how legal health records, both in paper and electronic forms/systems, should be used—during the entire life cycle of the EHR—including planning, processing, distribution, maintenance, storage, and retrieval of the health record to its ultimate disposition, archiving or destruction. Those who are significant to creating such a policy need to be experienced and knowledgeable (leadership) such as: physicians, legal counsel, risk management, and administration. In most cases, Health information management (HIM), Information services and technology (IT) are coupled in the equation as well. HIM professionals are responsible for managing operational side in terms of collecting, protecting, and archiving the legal health record (LHR) and work with IT specialists who manage the technical infrastructure and components of EHR. Working together as a team in addition to legal counsel (to protect against potential lawsuits) is crucial when it comes to EHR policy making.
Components of such a policy include: Health information exchange: the e-sharing (sending and receiving) aspect with other organizations/entities. Policies & Procedures as far as acceptance goes. If an organization is not able to accept such, destruction to the medium is necessary. Record completion: this ensures that any changes done to a health record are auto-updated to make sure information is concise/accurate. Amendments & Corrections are to include date/time and author authentication (full name, credentials, etc) and are to be electronically signed.
"Facilities with successful EHR systems are more likely to be those where HIM professionals played a role, according to newly released research." -Susan H. Fenton