Thanks to the stimulus package, electronic health records are a hot topic. But as in the early days of the eGovernment push, the reports of paper's death are greatly exaggerated.
A bevy of laws and regulations still dictate the use and retention of paper records across the healthcare industry. Federal and state law prevents physician's offices (and hospitals alike) from simply dumping paper documentation. So offices beginning the switch to digital shouldn't rush off to throw a paper shredding party just yet.
One OhMyGov! reader laments that the installation of an EHR system does not supplant his responsibilities to retain the paper files that crowd his undersized office. It's a baby step to the digital future, my friends.
The Paper Trail
Federal and state law dictate the length of time records must be retained. But administrators' fear of failing to comply with the law often prompts them to keep records permanently.
At the federal level, the Health Insurance Portability and Accountability Act (HIPPA) calls for files to be kept for 5 years, while states and third-party payers have there own set of regulations dictating how long files must be stored (pdf).
On average, states require files to be retained for 10 years. However, certain types of patient files may demand lengthier retention. Massachusetts requires a 30-year hold on inpatient care files, and North Carolina requires an 11-year retention.
Regulations vary by specialty and circumstance-physician office vs. hospital system, routine care vs. more emergent care. Many hospitals opt for file permanency out of fear that destroying patient information will place them at risk of litigation. Offsite storage facilities can serve an important role as conduits of the past while physicians' offices and hospital systems transition to electronic record format.
But even carting files offsite isn't a cure-all. Some regulations stipulate the type of storage required (onsite vs. offsite), so as is always prudent, especially in the healthcare industry, read the fine print! Pay attention to the relevant regulating bodies at both the state and federal levels.
So, amid the bureaucracy, can we get some guidance?
AHIMA, Aloha!
There are two main reasons why medical offices and hospital systems must safeguard patient documentation. First, a historical record of overall health, diagnoses and treatment is vital to future care. Second, if medical care goes awry or falls under scrutiny by patients and their representatives, a patient record is the only evidence of the medical event and communication among caretakers.
So how do EHRs alter traditional medical record-keeping practices? The transition to digital improves the quality and searchability of the record, but it also adds complications.
Who can view a record? Who inputs data? Who edits and stores it? Is the record secure? These are all questions being monitored by the American Health Information Management Association (AHIMA). The nonprofit group offers regulatory guidance for issues pertaining to health records and health information management professionals (the "HIM" in AHIMA).
While AHIMA has its roots in paper record keeping and the clerical nuances of providing prudent and thorough library cataloging, it is now neck-deep in linking library management to the digital age. Health information management positions demand IT prowess in order to be successful and navigate a heady world of regulation and technology.
One problem with the transition to EHRs so far has been the lack of clear standards of practice. Groups like AHIMA are important players in laying the groundwork for these standards, which address storage and security concerns, as well as the consistency in how EHRs are filed, deleted, accessed, duplicated, and more.
Standards will draw from numerous governmental policies such as HIPPA and the rules and regulations coming out of the Office of Health Information Technology (HIT). For entrepreneurs, a ripe business opportunity exists in simply disentangling the myriad risks associated with patient documentation, storage and retention. In the meantime, keep those file cabinets around. Whatever your office transition plan is for EHRs, you can put away the shredder-you won't be needing it much.
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