Before various technological innovations, medical records management was plain and simple. Patient information was recorded on patient charts and paper documents. Then, they are stored in filing cabinets. In recent years, medical practices have drastically changed, so have patient records and their management.
According to cdc.gov, 85.9% of office-based physicians use electronic medical records (EMR) and electronic health records (EHR). EMR and EHR systems are used to manage paper charts in a digital environment. A lot of technological advances in diagnostics and analytics have taken place in recent years. As a result, there is more patient data than ever. However, providers should comply with the Health Insurance Portability and Accountability Act (HIPAA)to protect the confidentiality of patient data.
Healthcare organizations have a legal and ethical obligation to protect patient data at all times. They are also responsible for the implementation of proper medical records management within their system. Failure in doing so may result in problematic medical errors and data breaches, which will lead to costly legal fines.
What is Medical Records Management?
Medical records management is defined as the set of protocols and procedures which are responsible for managing patient data throughout the entire lifecycle of the data. From the moment the patient information is entered into the hospital’s system, it should be properly stored, protected, and maintained. Patient data has its so-called retention period, which is the amount of time that it needs to be stored in the system before it is destroyed. Medical records management has a complicated set of protocols that must be followed at all times. Failure to do so may put patients at risk.
According to a study by Johns Hopkins, the third leading cause of death in the US is medical errors, with heart disease and cancer as the leading two respectively. Some studies have shown that the adoption of EHRs has improved patient safety. However, poor medical records management can lead to errors in medication, incorrect diagnoses, treatment lapses, and worse, life-threatening scenarios.
The security of patient data may also be at risk. Patient records are confidential and contain highly sensitive information, and when an oversight occurs, the privacy of patients is compromised. Healthcare data breaches are rapidly increasing, which made patients lose their confidence in sharing their medical histories.
Poor management of patient records also leaves healthcare organizations vulnerable to expensive fines, criminal charges, and lawsuits.
How will providers properly manage medical records? Here’s how.
Keys to Successful Medical Records Management
The healthcare system is quickly changing every single day, and healthcare data management can be demanding. Even so, there are certainly some tips that can help healthcare organizations can utilize to protect the privacy of their patients and maintain compliance with federal state laws.
Regularly perform self-audits.
Organizations must regularly check their system to prevent any untoward incidents from happening. HIPAA also conducts regular audits on healthcare organizations, so it is best that your system is in tip-top shape at all times.
Performing regular audits will ensure that appropriate measures are always in place to protect the privacy of patients. Also, performance and compliance monitoring are required to prevent data breaches which may result in risks in patient safety.
Be firm in implementing medical records management protocols.
Clearly and accurately lay down your security policies and procedures to your entire organization. This way, you will successfully streamline healthcare data management. It is important that your staff have enough knowledge on this matter because successful medical records management programs engage the entire organization.
HIPAA requires that the policies are written and retained for at least six years. These policies may need updating from time to time due to some changes in the organization.
Train your employees on how to manage healthcare data.
Most data breaches are a result of hacking, but there are some instances when the breach is a result of untrained employees. In fact, a recent study revealed that 50% of cybersecurity incidents at small and medium-sized businesses are caused by careless employees.
Per HIPAA requirements, organizations should train each employee who handles patients during any stage of the data life cycle.
Use comprehensive file names and labels on healthcare data.
Organizations need a taxonomy and indexing system that is easy to understand. It is easier to monitor patient records throughout their life cycle if they are labeled and organized properly. Furthermore, this assures that retention schedules are adhered to. Searching files will also be more efficient, which saves time, effort, and money.
Invest in reputable healthcare IT solutions to help you automate your processes and improve data security.
Complex state and federal laws make it difficult to maintain compliance, that is why you may need help from a company that does its best. In the medical field, there is little to no room for human error. Automating vital processes can significantly improve accuracy, and protect patients in the long run.
Furthermore, you need to keep your patient records secure from their point of entry into the database until they are destroyed. Having trustworthy data archiving software will ensure that your data is secured, 24/7.
The Future of Medical Records Management
As technology in healthcare continues to advance at a rapid phase, the healthcare system must keep up, especially in its approach to the management of healthcare data. If patient records are not safe and secure, both the patients and the provider are at risk.
On a good note, there are many steps that healthcare organizations can take to protect themselves and their patients. Taking a proactive approach to security and investing in reputable healthcare management software, healthcare providers can stay compliant with state and federal laws, thereby avoiding costly fines and lawsuits.