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December 7, 2009

Never Say Good-Bye?
By Greg Goth
For The Record
Vol. 21 No. 23 P. 10

A proposal to create a 10-year nationwide records retention policy has produced differing opinions on the merits of such a plan. Should healthcare organizations hold on to what they’ve got?

The retention and preservation of paper- and film-based medical records isn’t the sexiest topic, especially as so much emphasis across the healthcare industry is currently being placed on selecting and implementing EHR systems. However, the fate of decades’ worth of records on paper and film is receiving increased scrutiny precisely because the healthcare delivery system has reached a critical transition point between storing patient information on paper and in digital formats.

It should probably come as no surprise that some experts in the field are calling for a federal policy that will give providers and patients a consistent nationwide guideline for the length of time these old records must be retained. Such a nationwide policy, they say, would eliminate the confusing patchwork of laws and guidelines that differ between states, specialties, and agencies overseeing the licensing and certification of provider organizations.

However, other experts believe that, as we enter the dawn of the age of genomic medicine, records should be saved for at least the life of current patients and perhaps saved for their descendants, who might benefit from knowing whether markers or susceptibility for a certain disease potentially run in the family. Additionally, they say, the advent of PHRs will mandate that providers would benefit by erring on the side of having more records available, should patients begin compiling their own medical dossier and express a need for them.

A Uniform Policy
Ed Santangelo, senior vice president of healthcare at Boston-based Iron Mountain Inc, has proposed a 10-year nationwide records retention policy as part of the shift to EHRs. One of the oft-spoken benefits of a wholesale move to EHRs is a projected savings resulting from the instant and concurrent availability of digital records instead of relying on redundant copies of paper records spread throughout organizations. However, exactly how much money could be saved from the shift has remained an elusive target—particularly in the first year of implementation, when experts estimate a typical physician’s office may take a 30% reduction in productivity while staff learn the new system.

However, Santangelo, in an op-ed piece published in Roll Call, estimated that the shift to interoperable and certified EHRs could yield “perhaps $60 billion in savings over the next decade—but only if Washington mandates a national standard for the treatment and custody of patient records.”

Developing and adhering to the standard, Santangelo wrote, will require a strategic plan for the transition to digital records.

“Such a plan will dictate the duration that a healthcare provider will be required to maintain a patient’s physical paper and film records,” he said. “A tremendous amount of the current cost of maintaining patient records comes from the labor involved and the rents paid to manage giant file centers—in some cases stretching for acres—on each patient who is treated, regardless of whether an electronic patient record system is in place or not.”

Mary Lahey, vice president of account management for Iron Mountain’s healthcare group, says the idea behind Santangelo’s essay was to draw attention to the hodgepodge of state laws and replace them with policy adhering to existing best-practice guidelines recommended by the AHIMA.

“In order to successfully transition to the EHR and to have it be a way every organization can have a consistency of what information they are required to maintain for their patients, we need a single standard across the country,” Lahey says. “And we strongly recommend we follow the AHIMA guideline of 10 years from the last date of activity.”

Lahey says the wide disparity between states’ records retention laws and what information is required to be in those records will actually inhibit the creation of an interoperable health information network.

“We need to have a consistency across all the states and have a consistency that defines what we mean by retaining the information for the patient,” she says. “The transition to the EHR actually complicates it because it will be a hybrid record for a certain number of years. You don’t just turn a switch and say, ‘OK, they’re on.’”

Lahey says implementing the national standard will achieve greater importance as patients become more savvy about their role in maintaining their records.

“It will be important as we look at moving past the regional sharing of information and go to national ability to do so,” she says. “If you live in a five-year state and I’m in a 25-year state, I have an expectation that I can get 25 years’ worth of history when I move. That’s not the case if the state I’m moving to has been destroying after five.”

In a written response to a question from For The Record, Santangelo said the company will continue to pursue the initiative: “Iron Mountain is engaged with lobbying organizations and other parties in Washington to encourage congressional, policy, and other legislative leaders to examine the retention issue as part of the ongoing dialogue surrounding healthcare reform. Iron Mountain is leveraging its sizable customer base in the healthcare industry, along with our deep relationships with more than 1,500 federal entities, to advance this discussion through advocacy, one-on-one conversations, and other tactics designed to reach those decision makers.”

However, Margret Amatayakul, RHIA, CHPS, CPHIT, CPEHR, founder of Schaumburg, Ill.-based consultancy Margret\A Consulting, says she is not sure a blanket federal retention policy would either streamline HIM procedures or improve patient care.

“Let’s say they say you must keep records a minimum of 10 years,” she says. “There will still be some who want to look back 20 to 25 years, even if they will never see the patient again. They may still want those for research.”

Amatayakul also says patients may come to expect that any provider with whom they have a clinical relationship will keep their records as long as clinicians keeping them well past mandated storage periods.

“My concern would be, as a patient, if the policy is 10 years and most of your providers keep them for 10 and one keeps them for 20, then there is the potential for an adversarial situation with the ones who didn’t,” she says. “There are so many other things we need the government to do or to have some sort of federal policy in place, I don’t think this is as important.”

“Like a Note From Hippocrates”
Milton Corn, MD, deputy director of the National Library of Medicine in Bethesda, Md., says the medical community should think more about reasons other than statute of limitations requirements for long-term preservation of paper, film, and digital records.

“I think the expectation most people have—that somebody is keeping track of their health records while they live—is reasonable, and I would think 10 years is much too short,” he says.

In an essay titled “Archiving the Phenome: Clinical Records Deserve Long-Term Preservation,” published in the January-February issue of the Journal of the American Medical Informatics Association, Corn argued that expected patient care advances in the coming decades, coupled with more patient involvement in maintaining their own records, will actually encourage providers to archive old records for a century or more.
This strategy, he says, will likely happen at regional teaching hospitals with renowned reputations. Archiving such a long record, he says, will be motivated by patient care rather than the various states’ statute of limitations for legal action that are now predominant in retention regulations.

“A pragmatic push for the really serious medical centers to preserve things could actually be done if it got some traction,” he says. “Paper preservation is not really concertedly being done, but many do not discard records, regardless of statutory requirements. There’s no public report on who’s doing what, but many people don’t like to throw anything out.”

For example, Corn remembers calling for an old chart while working at Brigham and Women’s Hospital in Boston. In that chart, he found a note from neurosurgical pioneer Harvey Cushing, MD.

“That’s like having a note from Hippocrates,” Corn says.

John King, chief operating officer of EvriChart, a records management company, says that rather than sign on to a nationwide crusade to bring every provider organization in line with a blanket federal policy, HIM managers should begin planning for a hybrid record-keeping and retention system that can meet both state retention statutes and the privacy and security provisions of the HITECH section of the American Recovery and Reinvestment Act (ARRA) for at least the next five to 10 years.

“Say your facility decided to go fully EMR on January 1, 2009,” King says. “Everything up to December 31, 2008, is still in paper. We recommend you take one to two years of that paper, scan it, and get it in the electronic domain so it resides side by side with your EMR.”

For example, King says, up to 60% of emergency department patients will re-present some time within the next 12 months and, rather than call up a paper-based record, either in-house or through a records storage vendor, “it’s better to call that last visit up within seconds for continuity of care, billing and auditing purposes, or whatever that reason may be.

“For the years beyond that, say from 2006 and prior, at least be sure your records management associate can get that paper to you safely and securely according to HITECH,” he continues. “It’s not uncommon for us to see, if somebody had a cardiac cath in 2006 and they re-present in 2009, that they need that old record. HITECH says you need to have that stuff accessible.”

Developing a close collaboration between HIM and HIT departments will need to be an inherent part of devising a new hybrid retention strategy. Ironically enough, says Harry Rhodes, MBA, RHIA, CHPS, director of practice leadership at the AHIMA, older records are often quite succinct, while paper printouts created from digital systems often create reams of information that prove far more unwieldy to store.

“I was a director of HIM, and all the facilities I worked in kept the records forever,” he says. “One facility had records going back to 1917, and we would have people looking for their grandparents’ records for family illnesses. When they got them, they were like two pages, very truncated. Now, because of the digital nature of the records, they are getting larger and larger. Even master patient index vendors are saying when they do a conversion, they’re just going to move five years over because it’s just too much information.”

Patients as Archivists
Perhaps the most important person in determining what’s part of a vital medical record, and how long those records should be kept, is not an HIM or HIT expert but the person with the most to lose should those records be destroyed: the patient.

Rhodes, Lahey, and Amatayakul are among those who keep copies of their records, and Rhodes says he can envision a scenario whereby patients are offered institutional encouragement to do likewise.

“With the introduction of the personal health record and the medical banking model, I can see a role for the consumer in controlling what’s really vital and what isn’t,” Rhodes says. “People who have chronic disease are quicker to keep track of their records than people who don’t, who suddenly have an illness and they are scrambling around to piece together their health history—and they often find decisions have been made to destroy some of it. Culture does change, and we may find whether we like it or not, we’re being made more responsible for our longitudinal record.”

Amatayakul says healthcare providers must keep the patients’ expectations in mind when considering what to do with records.

“Everybody is entitled to keep their business records,” she says. “The point is that while they are your business records and you are entitled to keep the original records, the patient needs to have access, needs to be able to correct the record and that has been another whole issue. My sense is the Iron Mountains of the world have to move forward, too, and I can see them becoming health record banks for patients.”

— Greg Goth is a freelance journalist from Oakville, Conn., specializing in technology and healthcare policy issues.