Medical records are fundamental in the healthcare industry and benefit both providers and patients. With their set of information about each person’s health history (diagnosis, treatments, laboratory test results), they can speed up treatment in case of future needs and even ease bureaucratic issues involving insurance.
A few years ago, the adoption of electronic health record (EHR) systems was greeted with enthusiasm, replacing the old handwritten medical paper files – the new system guaranteed better organization, practicality, and cost reduction.
However, even with a modern system, requesting medical records remains complicated for many patients and healthcare professionals. There are federal and state laws and regulations related to medical record management that should simplify the processes but tend to complicate them instead.
Maintaining Medical Records
Passed in 2009, the Health Information Technology for Economic and Clinical Health Act, or HITECH Act, requires healthcare providers to convert their medical records to digital format and adopt electronic medical records (EMR) – a digital version of the patient’s chart for each treatment he/she performs.
EMRs can then be easily attached to electronic health records (EHR), which in turn are the patient’s medical records with their entire treatment history.
Since the HITECH Act, EHRs have increased in the United States. But keeping medical records involves many questions about the privacy of the data. This is where the Health Insurance Portability and Accountability Act (HIPAA) comes into play.
This 1996 federal law regulates the protection of patient health information and affects most health care providers (doctors, private clinics, hospitals, even pharmacies) and health plans. Among other details, the HIPAA Act states that patients are entitled to almost all of their medical records, electronic or otherwise, and gives them the legal right to inspect and review them.
More recently, beginning in April 2021, the 21st Century Cures Act banned the blocking of information, requiring healthcare professionals to provide free access to EHRs whenever requested by the patients themselves or by other healthcare providers who are treating them. Finally, each state has its own laws, and some provide even greater access to medical records than federal laws.
However, even with federal and state laws regulating the way medical records are maintained and transferred, there are still some flaws to be resolved. Among the difficulties that health professionals face with medical record regulation are the following:
Costs of Implementation
Some small clinics and independent practices still keep their medical records on paper due to the difficulty of purchasing an EHR software or even dealing with it later, as the system requires specific training for all employees.
In theory, EHRs should make the entire process faster and easier. But because there are different software in use, sometimes the file system of a database cannot be read or accessed by another system.
Private patient information in digital format has become a coveted article to hackers. There are cases where EHRs are stolen, and cybercriminals demand a reward for not disclosing the data.
Access by Relatives
The HIPAA Privacy Rule does not require a healthcare professional or health plan to share a patient’s medical record with their family or friends unless they are their personal representatives.
Refusal to Transfer Records
A 2018 study conducted with more than 80 hospitals across the US revealed that some hospitals simply did not follow general regulations, refusing to provide medical records requested by patients or charging very high fees to make them accessible.
Additionally, health care providers or facilities may face some other maintenance or management difficulties that can impact the way they handle and maintain medical records. The main one is how to properly deal with revenue cycles. But, what is revenue cycle management in healthcare?
This is the name given to the entire financial process carried out by healthcare facilities from the first contact with the patient until the payment after the services are provided. The process can be facilitated using RCM software.
Technology To Save Lives
There are still some issues to be clarified regarding the best ways to maintain, handle and transfer medical records, but no one is questioning the validity of the federal laws that regulate the subject.
New technologies, although challenging, come to make processes more agile and standardized, facilitate access, and speed up future diagnoses and treatments. Gradually, the most complicated or inconsistent part of all these processes must be resolved, ensuring greater transparency and easier access to patients’ medical records.