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"It's hard to let go of medical records," says Michelle Dougherty, practice manager at the American Health Information Management Association (AHIMA), a 50,000-member organization dedicated to the effective management of health information. Dougherty notes that some physicians believe in having medical records available for the lifetime of a patient; others keep records for 20, 30, or 40 years. Whatever your decision, it's important to have in place a clear plan in order to maintain patient privacy while ensuring appropriate access.
Rules on medical record retention vary by state. Dougherty says that states typically require that records be kept for seven to 10 years. Records for minors generally need to be kept 10 years past the age of majority (usually age 18), although this retention length also varies by state. Beyond those guidelines, a practice's legal counsel may be able to offer advice on record keeping.
Traditional paper-based record systems have their advantages — computer viruses can't disable your file drawer, for example - but they are not exactly compact. And practices need to develop detailed plans for keeping recent, active records close at hand while storing older records in an organized and secure manner.
For example, Columbia-Eastside's Dermatology Department in New York has developed a multitiered system of record keeping under the guidance of practice manager Cheryl Moore. The most recent records are kept in high-density sliding file drawers next to the front desk. Two-year-old files reside in cabinets in a dedicated room elsewhere in the practice; three- and four-year-old files are no longer kept in the office itself but stay in the building inside a secure storage area. Files more than four years old are stored offsite for three more years, then shredded under the supervision of office staff.
In finding offsite storage for patient records, practices need to choose a location that best protects the integrity of the records and the privacy of the patient. "Before purchasing your own storage area, consider the risks of flood, fire, and burglary," advises Dougherty. "Patients trust you to keep their records secure, so any loss or theft of those records can be a media nightmare of bad press for a physician." She recommends using a professional record storage company with levels of security and protocols for limiting access to personnel you authorize.
When it comes to destroying paper records, the files can be pulverized, shredded, or burned. The exact method doesn't matter, but a member of the practice staff must supervise the file destruction in order to ensure that the records have been completely destroyed and the privacy of patients protected. Dougherty advises, "The important thing is to use a vendor who specializes in confidential information and who can give you a certificate of destruction. You want to make sure that the files are not just left in a landfill or in someone's truck where there is the potential for breach of confidentiality and attendant liability issues."
To avoid dealing with endless file drawers, secured warehouse space, and document pulverization, many dermatologists have switched to electronic medical record (EMR) systems. From a regulation standpoint, it doesn't much matter whether paper records or EMRs are used for data storage; a practice still has the same government mandates (varying by state) to hold the records for a certain number of years, secure the privacy of the records, and completely destroy any records it chooses to purge in a manner that protects the privacy of patients.
EMRs do have some specific advantages. For example, instead of spreading data across various file drawers and locations, EMRs theoretically allow a physician to retrieve a stored patient record from any computer terminal in a practice office. Patrick Boyle, an EMR and storage expert with IBM's Global Healthcare Business Unit in Amherst, N.H., says that today's systems commonly allow practices to automate data disposal when records reach an age chosen by the practice.
The Healthcare Information and Management Systems Society (www.himss.org) can provide useful information for practices trying to choose an EMR vendor. Boyle urges consideration of not just the technology itself, but also the extent to which the vendor will customize the system according to the practice's specific record-keeping needs and traditions, and the degree to which the vendor will guarantee system performance and provide timely repairs should problems arise. "We've all had the experience of calling into an airline reservation system and being asked to call back because the computers are down. If that happens in a dermatology practice, you lose patients," says Boyle.
Practices need to decide which storage medium makes the most sense for data storage. Because patient records are held for years or even decades, it's important to try to choose a medium that won't become obsolete next season. Or as Boyle puts it, "You don't want to go with Betamax when you should have chosen VHS."
Which types of storage media seem most likely to stand the test of time? Most, if not all, EMR software vendors adhere to well-known industry standards for storing information online on computers. For long-term archiving in the practice environment, Boyle notes that physicians can have confidence in their ability to retrieve data stored on CD-ROMs or on a type of tape technology called linear tape open (LTO). Dermatologists can store these types of removable media offsite to protect practice data from fire or theft.
Protecting against system crashes and lost data is vital. "Some practices do two data backups - a regular one daily and a large backup weekly. One backup is kept onsite and one is taken offsite," says Dougherty. "Practices can also maintain a 'hotsite' (a duplicate copy of their system in a different location) or contract with an application service provider (ASP) that guarantees to securely host EMR software via the Internet at a remote location." ASPs assume the burden of choosing the right storage medium and properly securing it, but the dermatology practice itself must still evaluate an ASP's safeguards before entrusting it with sensitive patient information.
Even if an EMR vendor guarantees data security, that doesn't mean that a dermatologist will stop worrying about the safety of electronic records. Over the past 18 months, Michael H. Gold, MD, replaced the handwritten notes in paper file folders at his Gold Skin Care Center in Nashville, Tenn., with sleek tablet PCs and heavy-duty scanners and shredders. Gold never had a problem over a dozen years of storing paper records at warehouses, but now that his practice's patient data are housed on networks connected to the Internet, he worries about data security. Still, Gold believes that the electronic record system will benefit the practice by reducing paperwork and freeing office space previously used to store physical records. More and more dermatology practices will likely take the same path and implement their own EMRs in years to come.
Although an EMR can certainly bring advantages in record accessibility, organization, and automatic disposal, practices should remember than an EMR is not a silver bullet to fix every bottleneck or delay in your dermatology office. Whether you stick with paper or go a more high-tech route, the system must ensure security and patient privacy.
Once you've established a system for keeping your patients' medical records organized, secure, and accessible, exactly how long do you need to keep them? The answer varies from state to state, but AHIMA publishes detailed guidelines on medical record storage and disposal:http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_012545.hcspandhttp://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_016468.hcsp?dDocName=bok1_016468
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