Product EHR RMES FP

Product Brief - HL7 EHR Records Management and Evidentiary Support Functional Model [Functional Profile] (EHR AO FP)

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Product Name

Electronic Health Record Systems - Records Management and Evidentiary Support Functional Model
[Functional Profile] (EHR AO FP)

Standard Category

Application Functional Specifications

Type

Normative, ANSI Standard

Releases

• Normative Sept 2008, ANSI/HL7 EHR RMESFP R1-2010

Summary

The Records Management and Evidentiary Support Functional Profile provides functions in an EHR system that can help an organization maintain a legal record for business and disclosure purposes, help reduce a provider’s administrative burden, and reduce costs and inefficiencies caused by redundant paper and electronic record keeping. The profile, registered in June 2007, became a fully ANSI accredited standard in 2010.

Description

This profile is to identify universal records management principles including functionality for EHR systems. International and US federal guidelines, standards and laws will be considered in the development of RM-ES requirements.

An EHR-S must be able to create, receive, maintain, use and manage the disposition of records for evidentiary purposes related to business activities and transactions for an organization. One of the secondary uses for EHR data is medico-legal purposes – ISO 20514 defines medico-legal purposes as evidence of care provided, indication of compliance with legislation, and reflection of the competence of clinicians. This profile establishes a framework of system functions and conformance criteria as a mechanism to support an organization in maintaining a legally-sound health record. Since legal validity is at stake for uses of electronic records for evidentiary purposes, including admissibility of medical records, the RM-ES profile is important to health care operations and to interoperability.

Business Case (Intended Use, Customers)

HIM professionals, record & information management (RIM) professionals, IT professionals, clinicians, consultants, physicians, vendors, attorneys, and others

Benefits

It sets a foundation for other derived profiles to establish realm-specific language related to laws and regulation for the health record contained within the EHR-S. The profile is unique because it does not stand on its own. The profile should be coupled with a care setting profile, specifically care settings which are required by regulation or law to maintain health records. A care setting profile will identify the functionality and conformance criteria that support the collection of content for the required health record.

Resources

Work Groups

• For more information on the EHR-S FM and the HL7 Electronic Health Records Work Group, please visit: www.HL7.org/ehr.
• EHR WG Wiki
• EHR_RM-ES Project Wiki
• http://xreg2.nist.gov:8080/ehrsRegistry/view/listFunctionalProfiles.jsp?filter=all, NIST Functional Profile Registry

Education

• See more at http://www.hl7.org/implement/training.cfm

Relationship to/Dependencies on, other standards

• EHR-S FM

Links to projects in development

• None at this time