Over the past week I participated in a conference on practice efficiency and technology hosted by the Canadian Medical Association. As one of the presenters, I had an opportunity to talk with a number of physicians throughout the week. One of the most interesting discussions focused on the retention of paper and electronic medical records as required by law in Canada.
There is some variance in different provinces in terms of how long medical records need to be retained. It is my understanding that the general rule of thumb is 7 years from the date of last entry in a medical record in a private physician office or 7 years from the age of majority (which is currently 19 years of age). The British Columbia College of Physicians and Surgeons Policy on Retention of Records can be read by clicking on this link. In practical terms, this means that a physician with a newborn patient in his/her practice has to retain that record for 26 years.
There are a number of situations that are worthy of further discussion. I encourage physician readers of this entry to add your thoughts by clicking on the 'Comments' link at the bottom of this posting. These situations include the following:
- When a physician converts from a paper practice to an EMR, a core data set is usually entered into the EMR. This includes demographic information, long term medications, allergies and alerts, relevant clinical information and relevant diagnostic imaging, pathology and specialist reports. While some physicians may enter more information than others, the paper chart is generally not entered into the EMR in its entirety. During early visits, the physician may use both the EMR and paper record during encounters. Within 3 to 4 visits, the paper record is usually no longer required and is ultimately is placed into storage. For healthy young patients (children), very little information may be entered from the paper record into the EMR. However, this group is the one that requires the longest retention of the patient record by the physician. Even though the physician may be using an EMR, there is still a legal requirement to store the paper patient record for anywhere up to 26 years. I am not sure how one could avoid this situation without some mechanism to archive the entire patient record. Chart storage adds up to $$$ in the longer term. Thoughts?? How have physicians using EMR dealt with this issue?
- The second situation is one in which a physician who is using an EMR makes the decision to move to a new system. If the information in the first EMR is stored in a proprietary format (a format that is not standards based), it may not be possible to extract all the information from the EMR. In this situation, the physician may be faced with the need to maintain a copy of the original EMR at the same time as running the second EMR. This could be further complicated by the fact that the original EMR may run on an older operating system (e.g. an old version of Windows) and the fact that hardware needs to be replaced after a certain time cycle. The purpose of this second parallel system is simply to be available in the event that data is required for medico-legal or other clinical purposes based on the legal requirements in that province at that time. An alternative may be to print all of the patient records and store a paper copy, however this could create significant difficulty in finding the information month or years later. Any thoughts on how this situation could be managed?
- The last situation that we discussed was that of scanning consultant and diagnostic reports into the EMR. It is the practice in some EMR systems to scan consultant reports using Optical Character Recognition (OCR) software and then copy and paste the scanned text directly into the EMR. The benefit of this approach is the ability to search the text at the later time as it is in digital format. However there are also disadvantages in that the accuracy of the scanning needs to be checked (e.g. a Hyper being read as a hypo if certain fonts are used to print the document). In addition, if the source of the original document is then referenced in the EMR and the original document is then shredded, it is no longer possible to produce an exact copy of the original report, only a scanned version (which may or may not represent the entire specialist or diagnostic report). In addition, this is further complicated by the fact that the majority of specialists tend to maintain episodic relationships with patients. A patient is referred for a specific reason and may or may not follow up at a later stage with that specialist. If the specialist policy is to retain medical records for 7 years (in those over 19 years of age) and then the record is destroyed, it may not be possible to reproduce an original version of that specialist report beyond the 7 year time frame. This could have potential medico-legal ramifications as there would be no way to reproduce the exact report at a later time, as the original may no longer exist. Perhaps the only way to deal with this is to have a standard policy requiring that physicians retain an image of that document (e.g. as a .pdf file) and if there is a desire to have some of the information searchable in the EMR using OCR software, then an additional OCR copy can be placed directly into the EMR for reference or search purposes. This is a more robust answer, but the cost implications are significant as greater sophistication would be required in terms of scanning technology and it would take twice as long (or longer) to scan the reports directly into the EMR. The ideal end-state would be one in which only digital reports are inserted directly into the EMR, thus doing away with the need for scanning... however this is still some time in the future.
These are complex issues, but ones that have significant implication as we move to the EMR in physician practices.
The readers of this Blog would be most interested to learn the thoughts and experiences of others. Please add your comments by clicking on the 'Comments' link below.