Medical records and their management have evolved simultaneously as technology and medical practices. More than 85% of physicians now use electronic medical records (EMR) systems to maintain physical documents in a digital world. Let’s cover medical records management.
Thanks to breakthroughs in diagnostics and analysis tools, there is more patient data than ever before. However, medical providers must also follow strict federal guidelines to protect patient privacy after passing the Health Insurance Portability and Accountability Act (HIPAA).
What is Medical Records Management?
Medical records management is a set of rules and protocols that governs patient data throughout the data lifecycle. A patient record must be properly saved, safeguarded, and maintained from the moment it is created.
The record must be appropriately destroyed when kept for the required time (retention period). Medical records administration is governed by complicated rules and regulations with good cause.
Patients are put in danger when health records are misused. According to a Johns Hopkins research, medical errors are the third largest cause of death in the United States, after heart disease and cancer.
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What are the medical records policy and procedures?
HIPAA was enacted in 1996 to improve medical records administration and protect patients’ data. It lays out various records management procedures policies, including those listed below.
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Medical records security and storage:
There were no rules for securing or preserving patient medical records before HIPAA. Organizations are given leeway in designing systems that fit their size and needs, but HIPAA mandates some universal security measures. Organizations must do the following to stay in compliance:
- Train all workforce employees in medical records security protocols
- Limit access to locations where records are held or accessible
- Identify and proactively guard against predicted security concerns
- Monitor access through hardware, software, and procedures.
The Health Information Technology for Economic and Clinical Health (HITECH) Act was passed by Congress in 2009. HIPAA was fundamentally strengthened by HITECH, which increased security protocols and fines for violators.
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Medical records access and release:
A patient or the patient’s appointed representative has the right to access medical records under HIPAA. However, only with the patient’s agreement can a provider or insurer send medical records.
The Fair and Accurate Credit Transaction Act (FACTA), which was passed in 2003, adds another layer of consumer protection to the publication of medical records.
FACTA prohibits providers and insurance companies from exchanging medical records with affiliates, intended to limit the risk of consumer fraud and identity theft.
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Timelines for retention:
HIPAA, in most situations, takes precedence over any state rules that may apply to medical records. In terms of record preservation, however, HIPAA largely defers to states. As a result, requirements are complicated and differ significantly based on the state, record, and institution.
For example, doctors must preserve patient data for five years in Florida, while hospitals must keep them for seven. Providers in Nevada are required to keep records for five years or until minor patients attain the age of 23.
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Data destruction:
The practice of erasing information so that one cannot utilize it for illicit or unauthorized reasons is known as data destruction. HIPAA and FACTA both have strict data deletion policies.
Until patient information is rendered illegible and cannot be reconstructed, paper records must be shredded, pulverized, burned, or pulped. In addition, overwriting software or magnetic ways of destroying computer hard drives must be used to clear electronic information.
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Why is medical record management important?
Medical records that are complete and accurate enable healthcare workers to treat patients to their best abilities. In addition, every accessible detail is crucial since the information gathered can help with diagnosis and therapy.
Some studies suggest that hospitals that use electronic medical records increase patient safety, inadequate management can lead to prescription errors, missed diagnoses, treatment gaps, and other potentially fatal events.
Some reasons of importance:
- It is possible to enhance claim processing and reimbursement.
- The efficacy of therapies and treatments may be tracked and measured.
- It may form outcome forecasts with a rising quantity of data. From a legal standpoint, liability is minimized due to improved control.
- Information loss, mistakes, and omissions may be minimized using IT.
- Quality assurance is improved through accurate documentation of initial evaluations and progress.
- Methodical records of symptoms, diagnosis, and therapies will be extremely helpful to the next healthcare professional involved and the patient.
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Keys to successful medical records management:
Medical records administration can be difficult in today’s continuously changing healthcare environment. Organizations can, however, make efforts to protect patient privacy and maintain compliance.
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Establish medical records management processes:
A business must first identify its security policies and procedures to manage medical records effectively. HIPAA mandates that policies be developed and kept for six years.
Organizational changes that may influence the handling or security of patient health information necessitate updates. Medical records management initiatives that are successful involve the entire organization.
When writing processes, senior-level executives should seek feedback from every department that generates or handles records to ensure that all bases are covered.
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Develop comprehensive employee training:
While some breaches are caused by sophisticated hacking, others are caused by inexperienced employees mishandling sensitive health records.
According to a recent report, negligent employees blame more than half of all cybersecurity issues at small and medium-sized organizations. According to HIPAA guidelines, companies must teach every person who interacts with health records during every step of the data lifecycle.
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Labeling records properly:
Organizations need a robust taxonomy and indexing system that covers every type of record handled to monitor patient data from generation to deletion efficiently. It ensures that retention schedules are followed and that more efficient searching saves time and money.
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Automate processes:
Maintaining compliance with complicated state and federal laws is a difficult effort, and in the medical industry, there is limited space for human error. A unified medical records management system can improve accuracy, ensure consistency, and safeguard patients by automating crucial and time-consuming tasks.
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Improve data security:
From the time they are generated until deleted, patient data must be kept safe. When electronic records are in use, they should have a clear audit trail, and when paper documents are not in use, they should be securely kept in a location with limited access.
Records should be preserved offsite in climate-controlled, certified locations. Paper and electronic records should be securely destroyed using NAID-certified techniques at the end of their life cycle.
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Self-audit:
HIPAA performs regular and thorough audits to ensure that proper patient privacy safeguards are in place. In addition, organizations should implement performance and compliance monitoring and frequent self-audits to assure compliance and prevent fines.
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Benefits of medical record management:
1. Reduced Storage:
Compared to digital papers, it is clear that paper records take up a lot of space. Therefore, healthcare providers must ensure that all records are kept in files and that the information is kept up to date.
The clinic’s storage facilities will be overburdened with files and documents, necessitating additional labor to store and retrieve them.
2. Increased Accuracy:
One of the strategic initiatives used by health facilities to improve overall efficiency in converting paper to electronic medical records (EMR).
In a paper-based medical record system, medical errors such as illegible handwriting and insufficient documentation are common. Such blunders cause havoc on a clinic’s operations and may even result in legal problems.
3. Reduced Operational Cost:
The ultimate goal of a healthcare facility at any given time is to optimize its operations by generating earnings while minimizing costs. As a result, any improvement that can reduce operating costs is much valued.
Clinical content consultants play a critical role in assisting firms with cost-cutting initiatives. For example, it will greatly reduce the cost of implementing electronic medical records with the help of a consultant. As a result, the organization will reap good short- and long-term benefits.
4. Ease of Access:
One of the most inconvenient places to work is in a paper storage facility, especially when locating a certain file. It will always be difficult to track down a certain document unless there is a systematic, efficient technique of identifying the files.
Access and retrieval of electronic medical records, on the other hand, are essentially limitless. As a result, physicians can quickly and readily access a patient’s file and track their medical history.
5. Medical Data Security:
For patients, one of the benefits of telemedicine is that their medical records are kept safe and secure. Even though electronic medical records are vulnerable to varying degrees, their security is assured by many levels of protection. In addition, it improves the safety and security of EMR recordings.
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The future of medical records management:
The need for a more complex approach to medical records administration has arisen due to technological and healthcare advancements. Patients and doctors are both at risk when health records aren’t secured.
Penalties for non-compliant firms have risen with the number of data breaches. The Office for Civil Rights imposed a record number of HIPAA settlements in 2018, totaling $28.7 million in fines, up 22% from the previous year.
Fortunately, firms may take several precautions to protect themselves and their customers. Providers may stay compliant and avoid costly penalties and litigation by taking a proactive approach to document security and investing in centralized, complete medical records management systems.
Conclusion:
Medical records are an essential component of patient care. It is critical for the doctor and the medical institution to keep track of the patient’s records. It aids in the accurate evaluation of the patient and the formulation of a treatment plan.
In medical malpractice, the judicial system mostly depends on documentation proof.
intelyConnect helps you with the application, which helps to save patients’ records for the future. In addition, you can visit our website and check all the details about our applications and integrations.
