News & Updates
Why doctors still balk at electronic medical records
By Kevin Pho
Despite the fact that we can complete our taxes and perform complex financial transactions digitally over the Internet, medical records have faced an impasse preventing a transition to the digital age. Patient charts are still paper-based in most doctors' offices across the country.
President Bush's goal was for every American to have an electronic medical record by 2014. Both presidential nominees Barack Obama and John McCain's health reform plans include language that modernizes our health information system.
Despite the advantages of computerized records — including reduction of errors, improved preventive care and potential health care cost savings — adoption of the technology remains distressingly low.
The New England Journal of Medicine recently found that only 13% of physicians had made the transition to an electronic record system. The primary reason is financial. Upfront costs — which include purchasing servers, computers and software — can be as high as $36,000 per physician.
In addition, the learning curve for these programs is steep, increasing the amount of time a physician spends per patient.
For their efforts, doctors receive only 11% of the savings from electronic records, with most of the savings going to health insurance companies and the government.
In today's environment of rising office and malpractice costs, the decision for doctors to adopt digital records is fiscally unpalatable. David Brailer, former national health information technology coordinator in the Bush administration, puts it best: "The doctors bear all the costs, and others reap most of the benefit."
Furthermore, today's electronic record systems are riddled with problems. Many programs boil the patient encounter down to a series of "yes" or "no" questions that are then entered into the software. The resulting computer-generated notes are almost devoid of useful clinical information.
As Harvard physician Jerome Groopman says, encouraging doctors to ask restrictive questions can suppress open-ended dialogue with a patient, "which can be key to making the correct diagnosis and to understanding which treatment best fits a patient's beliefs and needs."
With hundreds of products on the market, few standards exist that would allow them to communicate with one another. Your primary care doctor might use one system, your specialist another and the local hospital a third.
One needs to look at the Department of Veterans Affairs for an optimal model. All of the VA's primary care physicians, specialists and hospital-based doctors across the country use the same electronic record system. It has played a significant role in the reduction of medical errors, optimization of cost efficiency, and attainment of high scores in preventive care measures.
Like other health indices, the U.S. lags other countries in the digitization of medical records. Modernizing our health information technology will be expensive, with estimates in the hundreds of billions of dollars.
Neither presidential nominee proposes enough financial resources to help doctors adopt computerized record systems. Combined with the dysfunction and incompatibility between the current crop of programs, the goal of universal electronic medical records remains elusive.
Kevin Pho is a primary care physician in Nashua, N.H., and blogs at www.kevinmd.com. He also is a member of USA TODAY's board of contributors.
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Medical Record Retention
Physicians have many responsibilities with respect to retaining medical records. A number of variables affect the length of time a physician should keep a medical record, such as state and federal laws, medical board and association policies, and the type of record (for example, an adult patient versus a pediatric patient record). The following information can guide physicians in developing their medical record retention policies.
Basis for Keeping Medical Records
The most important reason for keeping medical records is to provide information on a patient’s care to other health care professionals. Another major rationale is that a medical record that is well documented provides support for the physician’s defense in the event of a medical malpractice action. Without the medical record, the physician might not be able to show that the care he or she provided was appropriate and met the standard of care.
State and Federal Laws
For the most part, state and federal laws regarding mandatory record retention time frames apply to hospitals or similar facilities rather than to a physician’s clinic. The Medicare Conditions of Participation (COP) require hospitals to retain records for five years (six years for critical access hospitals),1 whereas OSHA requires an employer to retain medical records for 30 years for employees who have been exposed to toxic substances and harmful agents.2 HIPAA privacy regulations have a six-year retention requirement,3 which follows the federal statute for limitations for civil penalties.4
Medical Board and Medical Association Policies and Recommendations
When state or federal laws are silent on medical record retention, medical boards may have policies or recommendations on how long a physician should keep records. For example, the Colorado State Board of Medical Examiners Policy 40-07 recommends retaining medical records for a minimum of seven years after the last date of treatment for an adult and for seven years after a minor has reached the age of majority, or age 25.5 The California Medical Association has concluded that while a retention period of at least 10 years may be sufficient, it recommends that all medical records be retained indefinitely or, in the alternative, for 25 years.6
Case Law
A decision by the California Court of Appeals7 challenged the protection traditionally afforded to physicians by the statute of limitations. The court held that when an injury or abnormality did not manifest itself within the statute of limitation or if the patient could not have discovered the problem within the required time frame, the statute of limitations was suspended until the injury became apparent. As such, the time frame for the patient to bring a malpractice action was several years after the care was provided.
Recommendations
The Doctors Company recommends that physicians retain medical records for at least 10 years after the last visit for adult patients and up to age 28 for minors, or 10 years after the patient reaches majority. For California physicians, medical records should be retained for 25 years after the patient’s last visit. Some states allow records to be retained in an electronic format. For example, a paper record may be scanned to a computer or kept in another electronic format, such as microfilm. Paper records should be stored with a reputable document storage company.
Such companies may offer alternative methods for document management, such as electronic scanning and storage, which physicians may want to consider. Storing closed or archived records at your residence puts you at risk of damage from fire or flood, loss due to theft, or other unauthorized access. You should also check state statutes and professional licensing agencies for state-specific requirements or recommendations.
What Records Should You Retain?
Retain all records that reflect the clinical care provided to a patient, including provider notes, nurses’ notes, diagnostic testing, and medication lists. Retain records obtained from another provider for the same length of time as those in your record. This is especially true if you have relied on any of the previous records or information when making current clinical decisions.
As to billing records, physicians should review bills for any reference to care provided. For example, review the bill to determine if it shows a limited examination or an annual physical with diagnostic tests obtained or requested. If the billing document shows that care was provided, it may be in your best interest to keep the bill for as long as you retain the medical record. Otherwise, you need to retain it for the same length of time as other business records and in accordance with federal and state income tax requirements.
The Doctors Company understands that there are financial implications behind these recommendations. However, given the importance of the medical record in defense of a malpractice action, it is vital for the physician to have the record available to defend proper care.
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