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January 21, 2008

A Tall Order
By Mary Anne Gates
For The Record
Vol. 20 No. 2 P. 10

Getting ready for an EHR? That’s fine and dandy, but what are you going to do with your old paper records? There are several options that can help smooth the transition.

Moving to electronic health records is not as easy as merely choosing a software program that can capture, store, and retrieve patient records. Before a hospital makes the switch to electronic documentation, it must determine how to best store and manage current paper medical records.

“The time frame required to address these issues is typically at least six months based upon the current medical record forms policies and the level of bar coding,” says Leslie Mack, RHIT, senior director of HIM at CareTech Solutions, an HIT solutions provider in Troy, Mich.

According to Darice M. Grzybowski, MA, RHIA, FAHIMA, founder and president of HIMentors, LLC, in La Grange, Ill., most hospitals need at least 18 months to prepare for the makeover to adequately work on forms redesign, workflow analysis and change management, software configuration, interface/integration issues, staff training, equipment purchase, and archive record planning.

Several options are available to manage paper medical records, including the following:

• storing paper records on site or off site;

• back scanning or imaging all or part of the records;

• storing documents using microfilm or microfiche; and

• implementing more aggressive retention and destruction policies or decreased retention years.

Managing On-site Storage
“Storing paper records on site means paper records are easily accessible, and that the on-site space required to store paper records is inexpensive relative to the hospital’s overall HIM budget,” says Mack.

A well-organized filing system located close to the patient care area and adherence to good principles of basic record management help staff achieve easy access to necessary medical records, says Grzybowski, whose firm specializes in helping hospitals determine how to make the best use of space—both on and near site—to store medical records.

Reducing Clerical Errors
Although archived paper records are often a necessity with paper files, there is always the opportunity for clerical errors, such as misfiles and lost charts. One technique to avoid misfiles is to use a paper outguide slip, which makes it easier for staff to return a file to its correct location, says Grzybowski. “The purpose of the outguide slips is to ensure a match between when you pull a record and when you file it back to ensure it goes back in the same spot,” she says.

Grzybowski cites other important process controls for optimal on-site storage, including conducting chart audits to identify misfiles, keeping the charts neatly organized with enough room to remove records without damaging folders, regularly purging files, replacing torn folders, and reconciling records that have been checked out for several days.

Off-site Storage
On the upside, short-term off-site storage makes valuable hospital space available for more productive uses. It’s also less expensive than back scanning or imaging records, and additional staff are not needed to maintain the records. Mack points out that purging and moving the records is the responsibility of the records management company if one is utilized, while Grzybowski recommends having HIM staff handle the task.

Conversely, off-site paper record retrievals can be costly and prone to errors, as well as time-consuming. “Depending upon a hospital’s frequency of retrievals and its paper record retention schedule, storing paper records off site can become more expensive over time than scanning,” notes Mack.

Grzybowski has seen retrieval rates from off-site storage companies be as low as a 20% return in the first 24 hours, and retrieval charges reach thousands of dollars per week.

Also, out clauses at off-site storage facilities can be expensive if a hospital decides to move its medical records to a different location, says Mack, adding that, as with on-site paper records, off-site paper records are also available to only one person at a time.

Back Scanning
There are many advantages to back scanning or document imaging all or part of a record, according to Mack. Current and past information is readily available to all necessary medical staff simultaneously, which makes “tracking of access to patient records as required by HIPAA ... much easier.”

Further, scanned records do not take up space in the HIM department, there are no storage or retrieval fees, and a budget for supplies is not necessary, Mack says.

Back scanning also may reduce the number of HIM clerical staff necessary for day-to-day operations, while clinicians enjoy improved access to medical records and purging is both easier and more cost-effective, Mack says.

On the other hand, back scanning is not generally recommended by Grzybowski, who says she has yet to find a case where the technology has been worth the expense. “Not only are records not indexed properly during back scanning because previous historical medical records typically do not contain bar codes, but these images must be generally maintained and accessed by users of the records in separate software from the main EDMS [electronic document management system], causing additional technical problems and expensive software maintenance for the hospital.”

Microfilm or Microfiche
While it is true that medical records on microfilm and microfiche take up less space than storing paper medical records, Mack notes that they still must be maintained and some storage space for the film must also be made available.

Additionally, this type of film is still expensive even though it is old technology. A microfilm reader/printer must also be obtained to view the records, which are available to only one person at a time, says Mack.

Grzybowski says microfilm or microfiche tend to have similar price tags as back scanning but require separate equipment for review and are not as easily accessible.

Decreased Retention Years
Decreasing the time that medical records are retained is another way of addressing paper records storage. “Hospitals that employ more aggressive paper record retention and destruction policies do so because they can clearly identify the electronic medical record as the legal health record, avoiding altogether unnecessary expenses related to handling paper records,” says Grzybowski.

Document Disposal
Acceptable methods include shredding, incineration, and pulverization. Additionally, a certificate should certify the destruction of the records.

“Shredding by document management companies is the preferred disposal method,” says Mack, “with pick up and shredding to occur on site to minimize the potential for accidental mishandling of paper records.”

Learning From Peers
HIMentors cites several examples based on how client hospitals are dealing with historical medical record archive and retrieval needs, demonstrating that individual needs and solutions may vary and need careful cost and workflow analysis before a final decision can be made.

Facility A — Electronic health records already in place: A three-hospital system that has been electronic (EDMS in place for main HIM-stored medical records) for several years chose to take a mixed approach to record archiving needs. Older records had been stored on microfiche. More recent medical records from the several years prior to going electronic were back scanned by an outside agency into a simple indexed electronic system. Departments other than HIM that are still creating paper records are utilizing an off-site storage facility near the hospital for archive and retrieval needs.

This was the best approach for this facility since it had kept up with active alternative electronic media archiving and limited paper record storage on a long-term basis.

Facility B — Hybrid records (part paper, part electronic): An eight-hospital system is converting to electronic records and the implementation of an EDMS solution. Microfilming and off-site storage were the choice for archiving in the past. However, in more recent years, purging was not kept up-to-date by the facilities or their off-site storage company, creating increasing costs and storage needs.

The facilities decided to pursue a more aggressive destruction policy and centralize records into a facility run by a regional record center, reducing storage needs and costs and improving service to the information users. Eventually, the storage area will serve other storage needs for the hospital as records are destroyed over time and will continue to be used as a centralized document processing and retrieval center.

Facility C — All paper: A large state hospital with multiple clinics has just begun consideration of and planning for conversion to an electronic record. All storage has been on paper since the hospital opened, with little active destruction/purging. Multiple off-site storage facilities were being utilized on a contract or lease basis but are in the process of being converted to a facility-owned and -operated storage center for cost reduction and efficiency. The record center will also house other HIM functions and eventually be the center for electronic document management operations.

One Hospital’s Experience
When deciding how to manage medical records more than 10 years ago, St. Elizabeth Medical Center in Edgewood, Ky., attempted to plan for the unexpected.

“Historically, St. Elizabeth has kept the paper record as a ‘safety net’ in case of any type of legal action against the hospital,” says HIM Director Jon R. Kemper, RHIA. Since then, the benefits of ready accessibility to medical records have been carefully weighed against the drawbacks of the additional storage and retrieval costs of such a dual system.

“The positive is that you have the original medical record to compare to the scanned record if there is any type of legal case or compliance question. The negative is the associated third-party costs for storing and maintaining the record for years with a low retrieval rate due to the records being imaged,” says Kemper.

Since Kemper joined the HIM department of the 478-bed facility, he has looked at the current system of document management, as well as some alternative storage solutions. “When I started at St. Elizabeth 11 months ago, I began to ask the question as to why we have 10-plus years of imaged documents and also maintain the paper record instead of destroying the documents,” he says.

Currently, Kemper is making changes to the way that the approximately 500,000 medical records generated each year across all patient types will be managed. “I am moving St. Elizabeth to use the scanned health record as the official legal health record, with the destruction of the paper record 90 days after scanning and quality reviews of the record having been done,” he says.

The dual system is currently still in use at St. Elizabeth, but changes are expected to be implemented this year. “We are actively moving to the destruction of imaged records within the first six months of 2008 after 90 days postdischarge,” says Kemper.

A centralized warehouse for record storage is also being planned. “HIM took over responsibility of the hospital warehouse that was storing records for radiology and ancillary areas effective January 1, 2008. We are in the process of transitioning this warehouse into a dedicated record center where HIM professionals will manage all archival and historic health and business records for the organization,” says Kemper.

Hospital records now stored off site will soon be moving into a new home. “We will be transitioning all off-site records [now] in third-party storage to the dedicated record center within the first six months of 2008 and will be managing them centrally,” says Kemper. The dedicated record center is an off-site facility located only a few minutes away from the hospital.

— Mary Anne Gates is a medical writer based in the Chicago area.

View A Capsule Look at Storage Options here.

Off-site Storage Top 10 Tips
The following criteria serve as guidelines for HIM directors when choosing an off-site facility for storage of paper medical records, according to HIMentors Vice President Edward Stewart. Further, he says, these tips can assist HIM directors in contract negotiations.

1. Record storage companies should have guaranteed retrievability of at least 99% of the records requested within 24 hours, or there should be a refund of fees for the storage in proportion to the percentage of pulls per month.

2. Record storage companies should be asked to store the records in terminal digit order (or whatever order the facility originally had them stored in) and not placed randomly on shelves, locating them only with a bar code. This becomes a nightmare if records need to be relocated into another filing system or storage center.

3. Whenever possible, avoid box storage and ask that records be stored in open shelf storage for better and more rapid access. Urgent records should be retrieved with one-hour turnaround. Watch for extra fees for stat turnaround time and increasing fees over time.

4. Record storage companies should provide the facility with an ongoing inventory on a monthly basis (electronic and printed format, if requested) so it has an index and volume of all records stored at any time.

5. Record storage companies should provide an aging report to identify those records that should be destroyed according to retention schedules. When records are kept beyond retention life, there are often extra fees attached to the storage of those records.

6. Ensure that there are limited (or no) fees for returning your records if you discontinue using off-site storage.

7. Ensure that the contract for off-site storage has limitations on annual price increases and does not have a hidden auto-renewal clause.

8. Ensure that you know the hours of access (should be 24/7) and that there is adequate security, fire protection, insurance, and bonded employees working in the off-site storage area.

9. Ensure that the transport vehicles moving your records are insured for damages of loss, theft, physical damage, or breach of confidentiality.

10. Ensure that you have unlimited access to the premises in order to inspect the storage conditions of your records.