Healthcare organizations must remain legally compliant with document retention policies that govern patient records. Several variables affect the length of time a healthcare organization 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).
Historically, relevant materials went into a folder, and that compromised a patient’s chart. Charts were stored on-site or off-site in file storage that took up a lot of physical space.
Since the advent of electronic medical records and document management systems, much of these data can be stored electronically. But even electronic information requires digital storage, which has limits and can require multiple hard drives to grow capacity.
Managing document retention responsibilities
Healthcare organizations not only have a responsibility to retain records, but also for timely deletion and deprecation of older files that are no longer legally required to be retained. Documents kept past their required date may create legal and privacy-related concerns, while also exposing facilities to possible liability. Those disposed of improperly or inadequately may also create legal exposure. If documents are retained improperly, they can be readily recalled in discovery for legal cases.
Documents must also be disposed of in a responsible manner. Mass erasure through care-site queries runs the risk of unintentional deletions, which may also create liability. This can be an onerous process for hospitals and health systems. It requires time and resources to schedule, aggregate, and dispose of records, and it can’t all be done by one person.
Timeliness is also important, as maintenance needs to be done on a consistent schedule. Documents that require disposal may sit unnecessarily for months or even years, creating exposure and risk.
The Journal of American Health Information Management Association (AHIMA) publishes the Retention and Destruction of Health Information brief as well as case studies about information governance, a concept so important they adopted the Information Governance Adoption model for timely document deletion. AHIMA defines Information Governance as “an organization-wide framework for managing the information throughout its lifecycle, and for supporting the organization’s strategy, operations, regulatory, legal, risk, and environmental requirements.”
Supporting the digital document lifecycle
A document management and imaging solution (DMI) can make structured and unstructured data available to the right people at the right time. Hospitals and health systems can go beyond simply storing data to truly realizing the potential that is inherent in the information. The document retention and disposal feature available in the latest release of Quanum Enterprise Content Solutions provides a web-based application for hospitals and healthcare organizations to configure and apply facility- and document-specific retention policies and deletion requirements for digital records stored within their system. Qualifying files are queued for end-user authorization, and once approved, they are deleted. If enabled, the patient record or non-patient folder can automatically confirm deletion. The confirmation note is configured by your organization to include the necessary elements for audit and historical purposes.Specifically, the feature:
- Enables users to set and change disposal policies
- Includes an option for audit and confirmation tracking
- Creates an intuitive worklist for users to see charts eligible for deletion
- Provides an option for escalation to a supervisor or peer
- Allows alternatives for disposition other than delete for users
Following deletion, a notification of the event is delivered to the configured systems for detailed tracking. All functionality is configurable within the administration page so that organizations can create processes in accordance with their respective federal or state guidelines.Benefits of implementation include:
- A reduced hardware footprint, saving valuable space and money
- Proper disposal/deletion of records, helping to reduce legal exposure and liability
- Increased operational efficiencies by spending less time and resources managing a manual retention process
- Improved transparency through online tracking of records with audit and confirmation options
- The security of knowing that records are managed appropriately, and deleted according to legal parameters
Watch this video to learn more about document retention. To schedule a demonstration of the latest release of Quanum Enterprise Content Solutions from Quest Diagnostics for members of your organization, contact us at 1.888.491.7900, or send us an email.