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Journal of the Academy of Hospital Administration

A Study of the Storage Problems of Medical Records in Tertiary Hospital

Author(s): V.P. Bhaskaran*, Satyashankar P**, Tarun Koshy Abraham***, Naveen Kumar Pera****

Vol. 14, No. 2 (2002-07 - 2002-12)

Abstract:

The maintenance of the Medical Record is an essential task, advantageous to both the hospital and the patient. However the duration of preservation of records has long been a contentious issue. In today's era of cost-cutting and resource maximization efficient and space saving methods of records storage need to be used.The article discusses the medical record retention policy of a 1,500 bed hospital and the storage problems faced. It also lists the varied alternatives available and suggests a low-cost solution for hospitals in India.

Keywords : Medical Records Department, Record Retention Policy, Space Constraints

  • Duration of preservation of medical records has been a contentous issue since earlier times.
  • Clinician are not happy with the policy of destinction of medical records.
  • Newer technologies available for storage of records have been discussed, and easy to use, cost solution i.e. "filtering active files" for our country has been described.

Introduction

The Medical Records Department, in this study, was planned and built in 1970 for a 350 bed hospital when the daily occupancy was 240; the daily OP visits was around 230 and IP admissions 25 per day. The area of space of the MRD then was 3,500 sq. feet in which 10 years OP records and 10 years IP records were to be accommodated.

Now in 2002, the hospital has grown to 1,500 beds with the daily bed occupancy of about 950 beds; daily OP visits and admissions have also considerably increased. For the current workflow (about 80,000 new OP files per year) the MRD requires about 1,200 sq. feet space every year to accommodate the new OP files alone.

However the MRD has remained practically unaltered and space constraints make it possible to store only 3 years OP records here.

The MRD uses a unit numbering system with files stored in chronological order. The IP and OP files are linked by noting the IP number behind the OP file. Since retrieval of IP files is not urgent, IP files can be stored anywhere in the hospital but OP files must be stored in the OPD. In addition the MRD also stores MLC files and X-Rays of patients. Over the years a decentralized system was implemented and OP and IP files are currently stored separately.

Logistical Nightmare

The hospital receives about 80,000 new out-patients every year and the files created for these patients need to be stored in the MRD. Such large numbers of patients visiting the OPD has lead to a logistical nightmare and inspite of the best efforts there are invariably complaints from the patients. Doctors are also unhappy about the policy of destroying old files and with the time taken to retrieve and deliver some files. The inability to track the files once they have left the MRD also results in confusion and aggravation.

But the space constraints in the MRD meant that resources were used up in shifting and retrieving old files from godowns. To get around this problem, the MRD started a procedure of deleting hospital numbers of patients registered four years previously. All the files were moved to the godowns providing fresh space for about 80,000 files. As and when patients whose hospital numbers were deleted, revisited the hospital, a fresh numbers were deleted, revisited the hospital, a fresh number was created and the file retrieved from the godown. This was then attached to the new hospital number and the file stored as an active file. About 8,000 files were thus brought back to MRD and made 'active'.

The problem

The problem with this system is that a patient to the hospital was being issued with a new hospital number every four years. This led to several complaints from the clinical staff and patients. It was affecting long-term research studies and also interfering with the monitoring of patients who had to come for repeated check-ups. The problem was compounded with the introduction of a new PACS (Picture Archival and Communication System) network. This meant that hospital to permit proper filing and retrieval of his radiology images. Thus a system of retraining the hospital number of the patient and preserving the medical records according to the hospital policy (table 1) had to designed keeping in mind the pressing space constraints.

Table1 Hospital Policy with regard to retention/disposal of records in the MRD:

  1. Out-patient records not linked with in-patient records to be preserved for 5 years.
  2. Out-patient records linked with in-patient records to be preserved for 10 years.
  3. In-patient records to be preserved for 25 years.
  4. All medico-legal cases to be preserved for posterity.
  5. All medical records other than those mentioned above to be disposed off on a regular basis.
  6. All old X-rays relevant to the out-patient files that are being disposed off to be destroyed.

The Alternatives Available

There are several alternatives available in today. New technologies facilitate putting the records on a Local Area Network or even on the Internet. Records can be digitized and summarized and can be imprinted on a smart card. The availability of the PACS network and plans to implement the Hospital Information System (HIS) at the hospital meant that these proposals were also given serious thought.

Lack of medical data can lead to inefficient or inappropriate practice1 or to necessary care being delayed or withheld. An intervention that addresses even a fraction of this problem will have many financial and clinical benefits. The introduction of the electronic medical record was, in part, an attempt to solve this issue by making the record available on all hospital terminals2. New technologies use globally accepted standard platforms such as HTTP, HTML and the internet to reach a much more ambitious scope which will not need expansion. It is inexpensive to deploy, with evident potential benefit. The systems are compliant with the security requirements for the confidentiality of electronic health data published by the US National Library of Medicine3.

However, some states in the United States expressly prohibit the use of computerized records systems by requiring that orders be written in ink (often referred to as the "quill pen" laws), or by mandating that4 health record storage be restricted to original paper or microfilm.

As concern about breaches in internet security occupies more of the public and legislative agenda. "smart cards" are being considered a possible solution5. The low cost of the cards, their increasing storage capacity, and the fact that patients carry their card to the point of care make the smart card an attractive option either as an identification token or as a data container. However, people's tendency to lose small objects, the need for a standard format, and the problem of compatible hardware at the point of care are some of the reasons why smart cards are not gaining popularity. In addition, the cars must be physically present at the time information is reviewed, which makes remote consultation impossible. But it must be noted that about 90 million smart health cards were in use at the end of 1995, constituting about 13% of all smart cards in use. The French are already issuing smart cards to healthcare providers, and in numerous locations, including Canada, Germany, and Britain, healthcare smart cards are in use in pilot or operational settings6.

The other alternative would be to allow the patient to take control of their personal medical information7 and to keep his own file. People are already managing bank accounts, investments, and purchases on line, and many use the web for gathering information about medical conditions8. Consumers will naturally expect to extend this control to online medical portfolios9.

However the arguments against this are primarily due to the concerns that the Health Care Industry has about litigation and the increasing awareness among both the health care providers and the patients about their rights. The Medical Record is a most essential documentation of the care provided to the patient at the hospital and is invaluable proof in case of litigation. However, there are other issues at play as well.

In India the issues of privacy have not yet been raised. However with the solution of digitalization of the medical records and of placing them online, either on a LAN or on the internet, being considered in several modern hospitals, this is bound to come to the fore. Substantial problems arise if patients cannot trust that their medical data will be used only in the says they intend. If patients feel that they have no control over the fate of their medical information, they might fail to disclose important medical data or even avoid seeking medical care because of concern over denial of insurance, loss of employment or housing, or stigmatization and embarrassment. Expectation of privacy allows trust and improves communications between doctors and10,11 patients.

Patients should have the right to decide who can examine and alter what part of their medical records12,10. In principle a patient might choose to allow no access to such records, though at the risk of receiving uninformed and thus inferior care. At the other extreme some might have no hesitation in making their records completely public9. Although hospitals in India believe in maintaining their own records and not issuing it to the patients new judgments have made it mandatory that when the patient or his near relative demands from the hospital or the doctor the copies of the case papers, it is necessary for the hospital authorities and the doctors concerned to furnish copies of such case papers to the patient or his near relative13.

The Accepted Solution

In the hospital where the MRD was studied, about 1,106,864 medical records (both OP and IP) are currently in storage. A study conducted in the MRD for a period of four months revealed that 2,621 old OP files were requested (7,863 per year). Of this only 9.624% are for files older than 5 years. Thus it follows that if the files older than 5 years are microfilmed then the old file can be disposed off and this will provide the twin advantages of increasing storage space (744,569 files are of more than five years since origin) and of maintaining files for further referral.

After much consideration of the options available and taking into account the future installation of the HIS, a new system of 'filtering active files' was introduced as a temporary measure. This new procedure started with a cessation of previous policy: (deletion of hospital numbers). Instead the files earmarked for deletion were separated and when patients with these hospital numbers arrived at the hospital, their files were identified and stored separate from the 'recent' files in the MRD. Chronological order was maintained even though the continuous sequence was absent. Thus without any additional investment or creation of additional space the problem of having to delete numbers was solved. This system does not utilize any additional storage volume because the files, which are being retained, would have been made 'active' and stored in the existing space as per the earlier system.

Graph unavailable

Fig 1 {unavailable}

Graph showing the number of requests for medical records <3 years old, 3-7 years old, 8-12 years old and >12 years old from the MRD, over a 4 month period of study.

Conclusion

In conclusion, although technology is advancing at a breath-taking pace it is wise to adopt only those systems which are truly beneficial to improving the efficiency and resource maximization of the organisation. As mentioned above there are several high-tech solutions are available for storage of medical records but it is our contention that the easiest and most low-cost solution (for hospitals in India) would be a combination of filtering the active files and microfilming the older In-Patient files.

References

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  2. Barrows Jr RC, Clayton PD. Privacy, confidentiality, and electronic medical records. J Am Med Inform Assoc 1996; 3: 139-148[Abstract].
  3. Roy Schoenberg, Charles Safran. Internet based repository of medical records that retains patient confidentiality. BMJ 2000;321:1199-1203 (11 November).
  4. Testimony submitted to Congressional committees and federal agencies in 2000. Statement by the American Hospital Association to the Subcommittee on government Management, Information and Technology government Reform and Oversight Committee; RE: Medical Records Privacy, H.R. 52 (June 19, 1997).
  5. Neame R. Smart Cards the key to trustworthy health information systems. BMJ 1997;314:573- 577 [Full Text].
  6. Roderick Neame. Samart cards-the key to trustworthy health information systems. BMJ 1997;314:573(22 February).
  7. Ferguson T. Health online and the empowered medical consumer. Jt Comm J Qual Improv 1997:23:251-257 [Medline].
  8. Winker MA, Flanagin A, Chi-Lum B, White J, Andrews K, Kennett RL, et al. Guidelines for medical and health information sites on the internet: principles governing AMA web sites. American Medical Association. JAMA 2000;283:1600-1606[Medline].
  9. Kenneth D Mandl, Peter Szolovits, Isaac S Kohane. Public standards and patients' control: how to keep electronic medical records accessible but private. BMJ 2001;322:283-287.
  10. Gostin L. Health care information and the protection of personal privacy: ethical and legal considerations. Ann Intern Med 1997;127:683- 690[Medline].
  11. Institute for Health Care Research and Policy, Georgetown University. Health privacy project 1999.www.healthprivacy.or/(accessed 29 Nov.2000).
  12. Hodge Jr JG, Gostin LO, Jacobson PD. Legal issues concerning electronic health information: privacy, quality, and liability. JAMA 1999;282: 1466-147[Medline].
  13. Judgement issued by the Hon'ble High Court of Bombay in the case of Raghunath G. Raheja vs. The Maharashtra Medical Council and others

* Professor and Head of the Department of Hospital Administration, Medical Supreintendent, Additional Dean (Hospital Affairs), Kasturba Medical College Hospital, Manipal 576119, Karnataka,
** Associate Professor, Department of Hospital Administration, Assistant Medical Superintendent,
*** Post-Graduate, Department of Hospital Administration, E-mail: [email protected]

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