How to make sure your archived records are safe
Soggy or lost records not only jeopardize patient care—they can also lead to legal headaches
ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.
By Edward Martin
As he walked into his muddy office on the morning after Hurricane Hugo struck South Carolina with 120 miles-per-hour winds and devastating floods, Joseph L. Kurtzman, MD, realized the fish in his saltwater aquarium had fared better than the archives of his Charleston practice. Although his office was located a full mile from open water, his practice's records were not only soggy—many of them had been carted off by the storm.
"The front doors were completely gone, and the side doors were caved in," he recalled. "Two or three months later, people were still finding my records blocks away."
Dr. Kurtzman had anticipated practicing for another 10 years, but after a brief attempt to rebuild, the ophthalmologist retired in frustration. He had just turned 62. "Patients I'd seen 15 years before would come in. I'd have to scratch my head and say, 'Did I do this or that?' Rather than risk not doing a good job, I gave it up."
Although few physicians are affected so profoundly by damage to archived records, even seemingly minor problems can lead to disastrous results. "If you get sued and your records are gone or destroyed, you are going to lose, period," said John R. Irwin, MD, a physician and attorney in Cleveland.
Even worse, he explained, is the fact that jurors tend to equate lost records with intentionally destroyed records. An award of $500,000 for a wrongful death, for example, could be doubled or tripled in punitive damages if the jury suspects that the patient's records have been tampered with.
Despite such dire consequences, many physicians archive patient records in ways that make records managers cringe. "They put them in boxes in their garages," said Patti Reynolds, director of information services for the American College of Physician Executives in Tampa, Fla. A common result, she said, is that mice and insects destroy the records, or they are lost to fire or flood.
Harold Reeder, MD, a family physician in Jacksonville, Fla., works with some of the worst offenders—physicians who have been disciplined for failing to maintain proper records. As part of a course he teaches on the subject, he asks these physicians to send him samples of their record keeping, but not everyone complies. "I asked one doctor why he didn't send me any samples and he said, 'My grandfather and father were doctors. They didn't keep records, and neither do I,'" Dr. Reeder recalled. "I asked him what he did if a patient moved. He said, 'Well, the doctor there can call me.'"
That kind of old-fashioned approach won't work in today's practice environment. Patients and their physicians are increasingly mobile and need written records that can be mailed, faxed or even e-mailed. Perhaps even more importantly, explained Peter Waegemann, president of the Medical Records Institute in Newton, Mass., physicians need thorough records and archives to document their decision-making process if they are audited by a health plan or by Medicare.
With so much riding on your documentation of patient encounters, how well you archive patient records can be vital to your practice's success. Here are some tips on how to avoid trouble:
Know the basics. The Board of Healing Arts in Topeka, the state medical board for Kansas, has produced a guide that reflects how most states believe records should be archived. For example, physicians should preserve all notes, charts and records, said Mark Stafford, the board's general counsel. He also said that those records must be legible, use only abbreviations and terms common to the medical specialty, and adequately identify the patient and last date of professional service. Records must also indicate the patient's condition, diagnosis, medication and quantity prescribed, treatment and progress.
For more information on how your state requires you to store records, call your state medical board. You can also get additional information from groups such as the Medical Records Institute and American Health Information Management Association (AHIMA). (See "Where to get help on archiving records,")
Timing. How long should you archive records? The rules vary from state to state; in Kansas, records must be archived for 10 years, while in Colorado, it's eight years. "The hodgepodge quiltwork of state laws is incredibly complicated," said Dr. Irwin, the Cleveland attorney. "But the absolute minimum should be no less than five years from last patient contact." In the case of pediatric patients, he added, records must usually be stored until the patient turns 23, or two years after the patient becomes an adult.
Other factors complicate the equation. Mr. Waegemann pointed out, for example, that workers' compensation laws in some states require that physicians retain records for 75 years. To play it safe, many practices simply warehouse patient records indefinitely.
To be really safe, experts suggest contacting your state medical board or health department.
Preserve your records. If you choose to archive your records on-site, said Mr. Waegemann from the Medical Records Institute, keep them in rooms that are controlled for temperature, humidity and light. "Most of us know simply from leaving printed material on a windowsill that light will make the print disappear," he said.
You can prolong the life of your paper records by inserting anti-acid sheets between pages or using archival-quality paper, but both are costly, labor-intensive and cumbersome. You can store your records in waterproof storage chests, but that option can also be expensive.
A final consideration for on-site storage of records is fire. The National Fire Protection Association provides guidelines for minimum distances of shelves from floors and ceilings, aisle widths and fire protection.
Commercial storage. While you'll have to pay to store your records in commercial storage facilities, they are typically safer and sometimes even more economical than on-site archiving. Particularly in urban areas, where office lease rates can top $50 per square foot per month, paying for off-site record storage can be cost-effective.
Commercial alternatives range from high-security outfits like IBM Corp.'s Business Recovery Services, which has offices in most major cities, to monthly rental self-storage warehouses. Most medical practices find something in-between sufficient.
"A number of companies offer environmental controls, fire protection and cataloging at reasonable cost," said Harry Rhodes, a professional practice planner with AHIMA. One of the largest, Data Storage Centers Inc., is based in Florida and serves 27 markets throughout the country. Physicians can expect to spend $25 to $50 a month to store their records at these facilities.
Data Storage Centers offers vaults with flood and motion sensors and oxygen-displacing halon gas, rather than water sprinklers. According to Jim Spinney, president of Data Storage, most physicians choose conventional storage and keep bar coded records on open shelves. Retrieval in most cities costs $1 to $2 per file, with a $10 to $15 courier charge.
Electronic storage. Although paper records have a limited life, many physicians remain hesitant about making the leap to electronic archives. However, a number of developments may encourage the use of digital storage.
States are beginning to change their laws to permit physicians to electronically archive their patient records in lieu of keeping paper records. In October, for instance, Kansas began permitting physicians to put paper records on optical disks, microfilm and other media—as long as authenticity can be certified. That can be achieved by obtaining a statement of authenticity from the company converting the records, or having them notarized as true copies. "If not," said Mr. Stafford, "we still require the paper record."
Electronic archiving in general is also getting more legal recognition. For several years, the Uniform Photographic Copies of Business and Public Records Act, now adopted by 26 states, has recognized many forms of electronic archives, as has the similar Uniform Business Records as Evidence Act. "If your state has adopted those, it's a lot easier," Mr. Rhodes explained. "If your state is silent, a lot is still up for interpretation."
Federal agencies like HCFA encourage physicians and others in health care to use electronic archives. And even courts, which used to largely disregard electronic versions of patient records, are changing their attitudes. While lawyers continue to challenge the authenticity of electronic archives that are introduced in court, juries and judges are more inclined to view them as the real thing. "When a lawyer says, 'Gotcha!' because you don't have the original," Dr. Irwin said, "he's doing it mainly for theatrics now."
Optical disk storage has emerged as the leading technology for converting practice records, with systems available for less than $5,000. Small practices may benefit from other technologies such as Zip systems, which store greatly compressed data on disks similar to conventional 3.5-inch floppy disks. The disks start at around $100 but have limited data storing space.
Mr. Waegemann added that optical disks have an anticipated life of 10 to 30 years, which means that you can expect to periodically reload archives onto new disks. (A good source of information on data storage technologies is the American Society for Testing and Materials.)
Experts also warn against converting paper records by keyboarding them into your computer system. Mr. Waegemann explained that data without the physician signature or a legally acceptable photocopy are not admissible in court.
For now, most physicians seem reconciled to maintaining existing paper archives until their states permit destruction. However, most medical records experts believe paperless practices are coming, and physicians should consider installing systems that allow them to computerize new records.
Make changes carefully. Once you archive records, retrieving and altering them can render records suspect in later legal actions. "If you want to add something, be certain to do it as an addendum using new dates," said Dr. Reeder. If records are destroyed, as happened to Dr. Kurtzman, immediately call your liability insurer.
Overall, physicians will only be safe if they take a serious look at how well they archive. Mr. Waegemann urges physicians to improve their techniques. "We have statistics that indicate in 38% of patient contacts, information available to the caregiver is incomplete or not available," said Mr. Waegemann. "Can you imagine getting on an airplane and having the pilot tell you, 'Welcome to our airline, but 38% of my flight plan is missing?'"
Edward Martin is a freelance writer in Charlotte, N.C.
Where to get help on archiving records
Here are some contacts for more information on medical archiving and archiving technology:
American Health Information Management Association (www.ahima.org) offers information on medical records and archiving technology. Phone: 312-787-2672.
American Society for Testing and Materials (www.astm.org), offers storage recommendations for computer media. Phone: 610-832-9500.
Medical Records Institute (www.medrecinst.com) conducts research and education in medical documentation and patient information. Phone: 617-964-3923.
National Fire Protection Association (www.nfpa.org) publishes technical reports and makes recommendations on how to store records. Phone: 617-770-3000.
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