EHR RM-ES

EHR Records Management & Evidentiary Support (RM-ES) Project

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Project Overview

Welcome to HL7's EHR Records Management & Evidentiary Support wiki page.

The charge of the RM-ES project team is to provide expertise to the EHR work group, other standards groups and the healthcare industry on records management, compliance, and data/record integrity for, EHR systems and related to EHR governance to support the use of medical records for clinical care and decision-making, business, legal and disclosure purposes. The project team will meet this charge by completing the following:

1. Develop, ballot and refine the EHR-S RM-ES Functional Profile.
   • First RM-ES Profile developed against EHR-S FM Release 1, a new profile will be developed against EHR-S FM Release 2 in 2012/2013
2. Inform the EHR-S Functional Model and related standards on records management and evidentiary support functions and conformance criteria.
3. Monitor and/or collaborate with other standards groups (HL7, ISO, HITSP) as appropriate to provide expertise or to work on joint projects that develop, promote or refine RM-ES requirements for EHRs.
   • HL7 other groups such as the Interoperability Model, Structured Documents, Security
   • International standards organization such as ISO through EHR-S FM
   • Non-HL7 Standards Groups such as HITSP, Canada Health Infoway, etc.
4. Advocate for RM-ES issues in the healthcare industry as appropriate.

Refer to the RM-ES Project Team Charter for more information.

The 2010 RM-ES Workplan includes detailed information on the activities and work deliverables currently under development by the RM-ES team.

Task Group Leaders

Reed D. Gelzer

Provider Resources, Inc.

Phone: 203-506-5361

email: RGelzer@Provider-Resources.com

Diana Warner

AHIMA

Phone: 312-233-1519

Email: Diana.Warner@AHIMA.org

Work Group Team Members

Beth Acker

Bobbi Bonnet

Michael Brody

Chad Brouillard

Gary Dickinson

Barbara Drury

Michael Brody

Kim Baldwin-Streid Reich

Meeting Information

The RM-ES project team meets via conference call on a regular basis. The group may schedule a face to face meeting based on need. The RM-ES workgroup will report to the HL7 EHR Workgroup through their regular meetings or at the HL7 meetings.

• Standing Meeting Date/Time: Mondays at 12:00 PM ET/ 11:00 AM CT/ 10:00 AM MT/ 9:00 AM PT
• Full Team: Every Monday for 60 minutes
• Call Logistics
  • Audio:
    • Call-in toll-free number (US/Canada): +1-877-668-4493
    • Call-in toll number (US/Canada): +1-650-479-3208
  • WebEx:
    • 1. Go to https://ahima.webex.com/ahima/j.php?MTID=m973f093c3835da16dfd1afa40abc9472
    • 2. If requested, enter your name and email address.
    • ----------------
    • Meeting Number: 929 367 938
    • ----------------

Project Documents

EHR as Legal Record - ONC

Introduction: The HL7 EHR Workgroup invites ONC to consider near-term next steps toward advancing “EHR as legal record” issues in the EHR marketplace, referencing the international normative standard (ISO/HL7 10781 EHR System Functional Model Release 2), supportive resources, and subject matter experts. This invitation follows on related presentations to the US Health Information Technology (HIT) Policy Committee’s Clinical Documentation Hearing on February 13, 2013. Testimony was offered by Chad Brouillard JD, Michelle Dougherty, and Don Mon with subsequent support from Dr. John Halamka (past Vice Chair of the HIT Standards Committee (HITSC)) and Dr. Karen DeSalvo. Following the hearing, the HIT Policy Committee identified seven recommendations including standards development activities targeted to certified EHR systems maintaining a full legal record.

Problem Statement: Various EHR-related challenges pertaining to US legal domains are gaining visibility and generating drag for healthcare improvement and healthcare finance reform. Those arising from how EHR systems are designed, implemented, trained and used appear potentially amenable to mitigation through ONC and standards development activities. Three problem areas appear to distinguish themselves among subject matter experts and published reports as among the “most impactful”. As outlined in Mr. Brouillard’s “Statement from the Defense” summary (previously forwarded), these are: Audit Trail Usability, Export Distortion and E-Discovery.

Working Documents

Crosswalk - Common Events - MU 2015 Edition to ISO/HL7 10781 EHR-S FM and ISO 21089 Trusted End-to-End

Cost Benefit Savings Final

Notes with ONC January 2016

EHR WG Legal Record ONC Proposal

Statement from the Defense

EHR WG Legal Health Record Profile

S&I Data Provenance Recommendations

ONC "Record to Rely On" Workshop, 29 November 2016

Workshop Link

Medical Documentation and Clinical Reliability, Deborah Green, Diana Warner, AHIMA

Truth (Authenticity) as Evidence for Trust (Assurance), Gary Dickinson, CentriHealth

“To Verify” - An Opportunity for Compliance Assurance and Oversight in EHR-Sourced Records, Reed Gelzer MD, Provider Resources

Crosswalk Project

1. • Deliverable: A crosswalk between key criteria between the Lifecycle Model, CDA R2 Header, and RM-ES Profile to determine related metadata concepts and terms and work toward a single list of metadata concepts and definitions where possible.
   • Working Document: RMES CrossWalk Report
2. Evaluation of NPRM Meaningful Use and IFR Standards and Certification
   • Update on Meaningful Use NPRM & Standards/Certification IFR related to the Record management & Evidentiary Support profile
   • Working Documents

Legal EHR-S Gap Analysis

This analysis will identify gaps, overlaps, and conflicts between HL7 standards that support the Legal and Evidentiary Medical Records managementl; this project will determine whether the functional requirements identified in the Legal EHR-S Functional Profile - Release 1 are met. Our analysis will include but it is not limited to Domain Message Information Models: Medical Records Domain Model(RCMR_DM000050UV), Clinical Document Architecture Release 2(CDA R2)and its Implementation Guides. Secondly, this analysis will look at how the infrastructure functions common across EHR-Systems but identified as essential now by the Legal EHR-S Functional Profile - Release 1 are supported by HL7 security and privacy specifications (e.g. HL7 Role-Based Access Control Specification, and the Composite Privacy Consent Domain Analysis Model DSTU). Additionally, if workgroups have identified domain specific content (e.g. We will also look at areas of overlaps without attempting to specify the authoritative specification.

• Deliverable: Analysis of all conformance criteria that are associated with a function with priority "Essential Now" (EN) and "Essential Future" in the latest working copy of the Legal EHR-S Functional Profile that meet the following:
  • All functions in the latest working copy of the Legal EHR-S Functional Profilewill be analyzed and we will identify the standards or domains in HL7 that meet the requirements raised by the function and its associate conformance criteria. For Example 2.1.1.1 Legal Hold Notice was added as "NEW" with a priority of "EF" while 2.2.1 Metadata General is marked NEW with a priority fo "EN". Our analysis will look at both the functions and their criteria and identify the standards that address them
  • The analysis Conformance Criteria are marked to have been "added" (A) or "modified" (M) as well as those used unchanged.
  • The gap analysis will use the terms and conventions clarified in the RMES CrossWalk Report.
  • The gap analysis will identify gaps, overlaps,and conflicts in regarding the support of the functions and criteria.

Electronic Submission of Medical Documents (ESMD)-RMES Support Project

Project Summary for Electronic Submission of Medical Documentation(ESMD)-RMES Profile Support

• S&I Framework esMD Initiative wiki site
  • Author of Record sub group: The purpose of this work group is to investigate and recommend options to replace provider wet signatures on paper clinical documents with an electronic solution that provides document level proof of authorship. This solution must be identified in order for CMS to accurately authenticate who documented within the medical record, and trust the validity of the electronic claims attachments received.
  • Artifacts
    • Electronic signature regulatory requirements and standards

Completed/Archived Projects

This section contains Projects and associated documents that have been completed and/or archived.

1. ProjectName

RM-ES Standards Projects

1. The RM-ES Functional Profile Release 1 is registered on the HL7 EHR Work Group’s functional profile website, which is hosted by the National Institute for Standards and Technology (NIST).
2. The RM-ES Functional Profile Release 2 project is scheduled is in the process of launch Spring 2013
3. The EHR-S Functional model Release 1 Standard is available from the ANSI Approved Standards website.
4. The EHR-S Functional Model Release 2 project information is available from the EHR Workgroup Wiki

Related HL7 Workgroups and Wikis

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Listserv

The RMES Functional Profile Listserve is ehrwglegal@lists.HL7.org. To subscribe to this service, go to the HL7 Listservices Welcome Page