Preparing for a Deposition on an EHR
New Types of Information Lead to New Types of Questions
By Chris Dimick
LAWSUI TS CAN HINGE on a deposition. And while HIM professionals have long been called on to attest to the production of the paper medical record, electronic health record systems are introducing a whole new set of questions and considerations. Providing an accurate deposition on an electronic record requires knowledge of exactly how electronic information is generated, stored, and reproduced in the organization’s ystem, says Jennifer Moore, healthcare attorney with Bennett, Bigelow, and Leedom, based in Seattle, WA. “With the paper record, the number of questions that you are going to potentially be asked is somewhat limited,” according
to Moore. “And now [with EHRs], there is a whole other world
A deposition is a formal interview conducted between an
attorney and subject to raise facts that can be used in court.
HIM professionals typically provide depositions to opposing
plaintiff attorneys on how information is produced in the EHR
and how they assembled the information requested through a
Typical deposition questions include:
x How did the HIM professional arrive at a set of provided
x What were the parameters of the search?
x From what areas of the system were the documents
HIM professionals can also be asked to help interpret the
way information is stored and reproduced from the record.
44/Journal of AHIMA March 11
There are several differences between paper and electronic
health records that affect a deposition, Moore says. In most
EHRs, the record appears drastically different in printed form
than it does on a computer screen. Attorneys turn to HIM
professionals to help make sense of printed records that are
not as intuitive as paper records once were.
“Everyone knows how to read a paper record; very few
More Information to Explain
attorneys know how to read an electronic record,” Moore says.
“We are just now getting into the era of when we request a chart,
it is electronic. It is relatively new, so plaintiff and defense
attorneys both are behind the game in terms of knowing how
to read and analyze electronic health records.”
Deposed HIM professionals should prepare to receive
questions about the layout and organization of the medical
record in both print and electronic forms. Preparation for the
deposition should be done in part using the record format
provided to the plaintiffs, especially if that format is paper.
EHRs generate much more information about a patient
encounter than a paper record. Automatically generated
access logs, which can track which providers accessed a record,
when, and for how long, were not available in the analog paper
record. Every time someone enters and exits a record, his or
her actions are recorded in the log.
In addition, the time when records were entered into
a patient’s chart is available in many EHRs. Unless this
information was handwritten into a paper chart, it previously
wouldn’t have been available for attorneys to use in a case.
“Now we have records of exactly when things were done,
when people made entries, who made entries,” Moore says.