Health Information Management Technology PDF

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 8: Health Law ahima.org ahima.org © 2020 AHIMA Basic Legal Concepts How are laws classified? Public law vs. private law Criminal law vs. civil law Sources of law: Constitutions Statutes Administrative law Judicial d...

Health Information Management Technology: An Applied Approach, Sixth Edition Chapter 8: Health Law ahima.org ahima.org © 2020 AHIMA Basic Legal Concepts How are laws classified? Public law vs. private law Criminal law vs. civil law Sources of law: Constitutions Statutes Administrative law Judicial decisions ahima.org © 2020 AHIMA US Legal System How are legal disputes handled? US court system District courts Circuit courts Supreme Court State court systems Trial courts (limited or general jurisdiction) Courts of appeal/appellate courts State supreme court ahima.org © 2020 AHIMA US Legal System (continued) Civil How are legal disputes handled? (continued) Dispute resolution Arbitration – Third-party makes decision Binding – Must agree with third party decision Non-Binding – Doesn’t have to agree with decision Mediation – Third party helps parties come to a decision impartial ahima.org © 2020 AHIMA US Legal Process Bringing a lawsuit Plaintiff(s): summons and complaint Defendant(s) Counterclaim Joinder Crossclaim ahima.org © 2020 AHIMA US Legal Process (continued) Discovery (pretrial) Discovery methods Deposition – asking questions face-to-face Interrogatories – answering written questions in writing Requests for production (documents or other pertinent items) Discovery tools (to compel receipt of information) Subpoena – Must respond Subpoena ad testificandum or subpoena duces tecum with authorization Court order Warrant ahima.org © 2020 AHIMA E-Discovery Parties obtain and review electronically stored data Governed in federal court by the Federal Rules of Civil Procedure Considerations Discoverable data Metadata Legal hold Spoliation ahima.org © 2020 AHIMA US Legal Process Trial Jury or bench trial Admissibility of evidence is considered Post-trial Collection of judgment (civil) or sentencing (criminal) Possibly appeals ahima.org © 2020 AHIMA Evidence Federal Rules of Evidence govern admissibility in federal courts Hearsay: out-of-court statement used to prove the truth of the matter Not admissible unless it meets an exception Health records often admitted through the business records exception to the hearsay rule ahima.org © 2020 AHIMA Evidence Hearsay Business records exception ahima.org © 2020 AHIMA Medical Malpractice Professional liability causes of action: Breach of contract Tort Intentional tort Negligence Medical malpractice refers to professional liability of healthcare providers ahima.org © 2020 AHIMA Physician-Patient Relationship Physician-patient relationship is based on a contract Express Implied Cause of action is breach of contract ahima.org © 2020 AHIMA Professional Liability Breach of contract Tort Intentional tort ahima.org © 2020 AHIMA Medical Malpractice Stemming From Negligence Torts Types of negligence Nonfeasance – not meeting standard of care (Ex. Not Ordering standard test) Malfeasance – Doing the wrong thing (Ex. Amputating wrong toe) Misfeasance – Typical Mistake (most common) Elements of negligence Duty to meet a standard of care Breach Causation Injury or harm All Elements have to occur ahima.org © 2020 AHIMA Medical Malpractice: Negligence Torts Types of negligence Nonfeasance Malfeasance Misfeasance Elements of negligence Duty to meet a standard of care Breach Causation Injury or Harm ahima.org © 2020 AHIMA A patient is advised by a surgeon to have their gall bladder removed. The patient does not follow-up on this advice. Six weeks later the patient is admitted to the hospital with severe sepsis due to an infected gall bladder. The patient ends up having their hands and feet amputated. The patient wants to sue the surgeon. Does the patient have a case? Medical Malpractice: Negligence Torts Types of negligence Nonfeasance Malfeasance Misfeasance Elements of negligence Duty to meet a standard of care Breach Causation Injury or Harm ahima.org © 2020 AHIMA A patient comes into the hospital with EBOLA. The infectious disease doctor at the hospital quickly recognizes the disease and begins treatment. The patient dies. The patient’s family wants to sue the doctor. Does the family have a case? Medical Malpractice: Negligence Torts Types of negligence Nonfeasance Malfeasance Misfeasance Elements of negligence Duty to meet a standard of care Breach Causation Injury or Harm ahima.org © 2020 AHIMA A driver is in a serious car accident late at night. At the scene a woman stops to help. Her husband, the passenger, is an emergency room physician. The doctor is very drunk and decides to not attempt to assist the accident victim. The patient bleeds to death at the scene. The patient’s family wants to sue the doctor. Does the family have a case? Medical Malpractice: Negligence Torts Types of negligence Nonfeasance Malfeasance Misfeasance Elements of negligence Duty to meet a standard of care Breach Causation Injury or Harm ahima.org © 2020 AHIMA A patient is having surgery to amputate an infected toe. The surgery proceeds, but the wrong toe is amputated. Afterwards, the doctor states the OR nurses marked the wrong toe, so he should not be held liable. The patient wants to sue the doctor. Does the patient have a case? Medical Malpractice: Negligence Torts Types of negligence Nonfeasance Malfeasance Misfeasance Elements of negligence Duty to meet a standard of care Breach Causation Injury or Harm ahima.org © 2020 AHIMA A patient goes to urgent care after work with a terrible sore throat. After waiting three hours the patient is finally seen. The patient asks why the wait was so long and the doctor explains that she was very tired and decided to take a nap on the exam table. The patient was given antibiotics for the sore throat and recovered quickly. The patient wants to sue the doctor. Does the patient have a case? Patient Rights Regarding Healthcare Decisions Consent General consent Informed consent Advance directives Durable power of attorney for healthcare decisions (DPOA-HCD) Living will Do-not-resuscitate (DNR) order ahima.org © 2020 AHIMA Legal Issues in Health Information Management Creation and maintenance of health records Ownership and control of health records, including use and disclosure The legal health record including content, retention and destruction ahima.org © 2020 AHIMA Creation and Maintenance of the Health Record What requirements affect the form and content of the health record? Statutory laws such as state and federal statutes Regulatory laws such as Medicare Standards by accrediting bodies such as Joint Commission Third-party payer requirements Failure to comply will likely result in some type of penalty ahima.org © 2020 AHIMA Creation and Maintenance of the Health Record Guidelines for complying with requirements should address issues such as: Record content and format Entries and authentication Authorship Language and terminology Receipt and transcription of verbal orders Documentation errors and amendments Analysis of documentation ahima.org © 2020 AHIMA State Laws Involving Use and Disclosure Privileged communication statutes Protect information shared as part of the physicianpatient relationship State laws may specifically provide patients with the right of access (in compliance with HIPAA) State laws may require disclosure without patient authorization Examples: vital statistics; public safety ahima.org © 2020 AHIMA Ownership and Control of the Health Record The health record is owned by the organization that created and maintains it Control of the record includes its use and disclosure Individuals have a right to access their own information, with some exceptions ahima.org © 2020 AHIMA Health Information in Judicial Proceedings Health records are usually admissible in litigation or judicial proceedings Authentication affirms a health record’s legitimacy ahima.org © 2020 AHIMA Legal Health Record (LHR) Is the official business record created by or for a healthcare organization Is the record that will be disclosed upon a valid request by third parties ahima.org © 2020 AHIMA Legal Health Record (LHR) Organizations should inventory all documents and data that could comprise the legal health record, considering all locations Electronic documents that may be part of the legal health record include: Emails and text messages Diagnostic images and electronic fetal monitoring strips Digital photography and video Metadata ahima.org © 2020 AHIMA Retention of Health Records When developing retention policies, consider: Applicable federal and state statutes and regulations Statutes of limitation for malpractice and other claims Accreditation standards Operational needs of the organization ahima.org © 2020 AHIMA AHIMA Retention Guidelines Ensure retention schedules are designed so patient information is available to meet patient care needs, legal requirements, research, education, and other legitimate uses Develop guidelines that specify what information should be retained, the retention period, and the storage medium Clearly specify the destruction method to be used for each medium ahima.org © 2020 AHIMA Record Destruction Must take into account Applicable federal and state statutes and regulations Accreditation standards Pending or ongoing litigation, investigations, or audits Storage capabilities Cost ahima.org © 2020 AHIMA Record Destruction Destruction may be performed by the healthcare organization that owns the health records, or it may be outsourced Documentation: Certificate of destruction or manner of destruction List of all destroyed records Agreement that assures protection of the information ahima.org © 2020 AHIMA Record Destruction Considerations for Electronic Information The information must be actually destroyed rather than merely deleting the pathway to access it The likelihood of duplicate records remaining in circulation is greater with electronic records ahima.org © 2020 AHIMA Medical Staff Credentialing Healthcare organization is responsible to establish policies and procedures to ensure reasonable care in medical staff appointments Credentialing for appointment and reappointment Clinical privileges to define the set of services a physician is permitted to perform National Practitioner Data Bank formed by the Health Care Quality Improvement Act of 1986 ahima.org © 2020 AHIMA Licensure, Certification, and Accreditation Licensure: allows an individual to practice, or an organization to operate Certification Individuals: designation of competence by a private organization Healthcare organizations: designation by US Department of Health and Human Services that its Conditions of Participation have been met Accreditation: designation of excellence by a private entity ahima.org © 2020 AHIMA