Costa, attorney and associate at Greenberg Traurig, LLP, in Boston, Mass. However, he adds, most of these organizations maintain warehouses where they store paper records that have been transcribed to electronic form. "There is resistance from some about going to a completely electronic format because there are still some questions about privacy," Costa says. "There is definitely still a place for paper-based medical records, but the focus from now on will be on making sure that information can be adequately secured" (Fiske).
Frederick Geilfuss, partner in the health law department of Foley & Lardner, in Milwaukee, Wis. says that while many larger providers have already begun the shift, he has not encountered any institutions that have made a complete transition -- an event that he believes is still in the distant future. "There are quite a few doctors out there who are not technologically minded and who prefer paper records," he explains. Changing from paper to electronic records requires organization, as well as technology, because a switch made on a going-forward basis would result in two sets of medical records -- paper and electronic -- with an increased potential for confusion (Fiske).
Health Information Management (HIM) professionals using paper-based systems are confronted by many of the same challenges regarding HIPAA compliance as their colleagues who have switched to electronic records. Although the legislation was originally intended to ensure security and privacy of electronically stored and transmitted information, it has evolved to include all types of communications. "HIPAA extends to any manifestation of patient confidentiality, including what people do in medical offices and what they say about confidential information," explains Henry E. Schwartz, partner in the business and corporate department in the Baltimore, Md., office of Blank, Rome, Comisky, and McCauley, LLP (Fiske).
The HIPAA security requirements for paper-based records are the same as those that apply to oral communications and electronic information, Costa explains. It will be necessary to ensure that the minimal amount of information is disclosed at any time, and providers will need to adhere to restrictions about uses of patient information for medical research and quality assurance purposes. Monetary penalties for noncompliance can range from $10,000 to $250,000, depending upon whether disclosure of information is accidental or for commercial profit, he says. There are also criminal penalties ranging from five to ten years in prison for willful release of patient information without patient consent (Fiske).
While securing paper medical records in either an office or at an off-site facility is often lock-and-key simple, it is always important to monitor and limit employee access to vital and confidential information. "There is really nothing new under the sun, as far as security measures, for paper medical records," says Schwartz. "Medical information has always been confidential, and, in the larger sense, HIPAA didn't change that." Although HIPAA does not specify the means by which requirements must be met, most security measures are simply based on common sense, beginning with an assessment of office practices in order to determine the current state of security for written and oral information, he says (Fiske).
Among the measures that Schwartz recommends are locking medical records files and restricting physical access to them; implementing a policy to ensure that no one enters medical files without authorization and reason to do so; developing a fax policy to ensure that faxed medical information is received by the person for whom it was intended; and, perhaps most simply, not leaving medical files on desks or tables around the office. "It's great that medical records are protected when they are in a storage cabinet," Schwartz comments, "but what happens when someone takes them out to look at them? Does the person leave them lying around while he or she leaves to get a cup of coffee" (Fiske).
As bulky paper records accrue, many healthcare organizations opt to store them in off-site warehouses or storage facilities. Historically, this has not presented any problems of which Schwartz is aware, but he cautions administrators to include security policies in contracts with off-site storage providers. He adds that, when disposed of, paper medical records should always be shredded. "If anyone gets a hold of them," he advises, "they should be unreadable and unrecognizable" (Fiske)
Discussion -- Perhaps EHR's aren't Safe Enough for a National Roll-out?
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