Not long ago, managing medical records simply involved recording patient information on paper charts and storing them in office filing cabinets. As technology and medical practices rapidly changed, medical records policy and procedures did too.
Today, the Health Insurance Portability and Accountability Act (HIPAA) requires that medical providers adhere to strict federal guidelines to protect patient privacy. As a result, more than 85% of physicians use electronic medical records (EMR) systems to manage physical records in a digital environment.
Medical professionals have a legal and ethical obligation to protect patient information and properly manage records. Failure to do so can result in medical errors and data breaches, which can lead to costly fines.
Understanding policies and procedures regarding medical records management can help organizations maintain compliance and protect their patients. Continue reading for an overview of everything you need to know.
What is Medical Records Management?
Medical records management refers to a system of medical records policy and procedures responsible for governing patient information throughout the entirety of the data lifecycle. From the moment a patient record is created, it must be appropriately stored, secured, and maintained. After it has been retained for the necessary amount of time (its retention period), the record must be properly destroyed. There’s a complex set of rules and regulations regarding medical records management— and for good reason. When health records are mismanaged, patients and their private health information are put at risk.
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Medical Records Policy and Procedures
Enacted in 1996, HIPAA was created to modernize patient information management and protect patients’ personal information. It outlines several records management procedures, including the following:
Medical Records Security & Storage of Medical Records
Before HIPAA, there weren’t standards for securing or storing patient medical records. Now, organizations are required to have certain security measures, but they’re also granted a certain amount of autonomy in creating systems that serve their sizes and needs. To maintain compliance when storing medical records, organizations must:
- Identify and proactively protect against security threats
- Train all employees in medical records storage security procedures
- Limit access to facilities where records are stored or accessible
- Implement hardware, software, and procedures to monitor access
In 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH essentially strengthened HIPAA, increasing security protocols and penalties for violations.
Medical Records Access & Release
Under HIPAA, a patient or their designated representative has the right to access records. A provider or insurer may only send patient records with permission.
Passed in 2003, the Fair and Accurate Credit Transaction Act (FACTA) provides an additional layer of consumer protection surrounding the release of medical records. Designed to reduce the risk of consumer fraud and identity theft, FACTA severely restricts providers and insurance companies from sharing medical records with affiliates.
In most cases, HIPAA supersedes any state laws that may apply to medical records. However, HIPAA generally defers to states in matters of records retention. Requirements are complex and vary widely depending on the individual state, record, and institution. For example, in Florida, physicians are required to retain patient records for five years, while hospitals must keep them for seven. In Nevada, providers must maintain records for five years, or until minor patients reach 23 years old.
Data destruction is the process of destroying information so it can’t be used for illegal and unauthorized purposes. Both HIPAA and FACTA have stringent data destruction protocols. Paper records must be shredded, pulverized, burned, or pulped until patient information is rendered unreadable and cannot be reconstructed. Electronic information must be cleared using overwriting software or magnetic methods of destroying computer hard drives.
Keys to a Successful Patient Information Management System
In today’s rapidly changing healthcare field, medical records management can be demanding. However, there are steps that organizations can take to protect patient privacy and maintain compliance.
Establish Patient Information Management Procedures
To successfully manage medical records, an organization must first clearly define its policies and procedures for maintaining security. HIPAA requires policies to be written and retained for six years. Updates are required when organizational changes could affect the handling or security of patient health information.
Be sure to engage the entire organization when establishing procedures. Senior-level executives should obtain input from every department that generates or handles records, ensuring every base is covered.
Develop Comprehensive Employee Training
While some breaches are the result of sophisticated hacking, others are the result of untrained employees mismanaging sensitive health records. A recent study found that negligent or careless employees were at the root of 56% of insider threat security incidents. Per HIPAA’s guidelines, companies must train every employee who interacts with health records.
Label Records Effectively
To efficiently monitor patient records from creation through destruction, organizations need a comprehensive taxonomy and indexing system that covers every type of record. This ensures adherence to retention schedules and makes searching more efficient.
Maintaining compliance with state and federal laws is a complex task, and there’s little room for human error in the medical field. By automating time-consuming processes, a centralized patient information management system can improve accuracy, assure consistency, and protect patients.
Improve Data Security
From creation through destruction, patient records must be secure. While in use, electronic records should have a detailed audit trail, and paper records should be securely locked in a room with restricted access. Records stored offsite must be held in certified, climate-controlled facilities. At the end of their life cycle, paper and electronic records should be securely destroyed using NAID-certified methods.
Perform Self Audits
HIPAA conducts regular and thorough audits, ensuring that appropriate measures are in place to protect patient privacy. To ensure compliance and avoid fines, organizations should institute performance and compliance monitoring, as well as periodic self-audits.
The Future of Patient Information Management
Advances in technology and healthcare require a more sophisticated approach to patient information management. When health records aren’t secured, both patients and providers are at risk.
As data breaches increase, so have penalties for non-compliant organizations. In 2020, the Office for Civil Rights issued more financial penalties for HIPAA violations than any other year.
Fortunately, there are many steps that organizations can take to protect patient information.
To securely manage both paper and digital medical records, healthcare organizations have found success with Access Unify™, which integrates with the systems already in use to improve efficiency and compliance. By taking a proactive approach to document security and investing in a centralized, comprehensive patient information management system, providers can remain compliant and avoid costly penalties and litigation.