A medical record is crucial to patient care and is a common sight in every healthcare facility and medical practice. As an essential piece of documentation, a paper medical record should always be kept safe with an adequate security measure and other safeguards against unauthorized access.
But how should manual medical records be stored and secured, and is there a better way of making sure that health records stay out of the wrong hands? Any paper record can be adequately protected with physical safeguards, employee protocols, and patient authorization. However, one of the best ways to keep this type of document safe is to convert it into an electronic health record.
Many practices today still use a paper record to keep track of a patient’s condition and overall medical treatment, and these paper records require a specific set of safeguards to ensure that no unauthorized person gains access to them. The most significant challenge that your practice will have to overcome with keeping manual medical records is their physicality: while it can be convenient to your staff and physicians, it also presents a unique set of challenges in making sure that crucial patient data stays private and secure.
Here are several steps that you should consider when protecting your practice’s depository of paper medical records:
The first thing that practices should always ask themselves is “who has access to these records?” Given that the likelihood of these records changing hands is quite frequent depending on the patient, it’s easy for paper records to end up in the possession of someone not authorized to have them. This can be problematic for several reasons, including but not limited to:
To counteract this, your practice must have a process and personnel list of everyone who can access and change information on a patient’s medical record at any given time. This can limit the risk of a third party accessing or tampering with patient data while the health record is outside your archives, and it makes any investigation easier if possible tampering has been detected in the record itself.
One way that you can increase accountability in document access is by requiring anyone who makes a change to a medical record to log their identity and the exact nature of their changes in the record itself. While this approach may add more time that your doctors, nurses, or other medical staff spend on record-keeping, it ensures that any change that’s made to medical records can be traced back to the specific staff member that did it.
Granting authorized access can also be delegated to higher-ranking staff members in case of multiple patients working on one doctor, though keep in mind that you should carefully screen these permissions before approving them. Authorized access isn’t necessarily limited to medical staff in your practice – interdepartmental couriers, record-keepers, and even maintenance staff should always be checked for their capacity to access your medical records.
Read more: Who Has Access To A Patient's Medical Records?
One of the simplest and most effective ways to store and secure medical records is to introduce some kind of physical safeguard to their access. This can vary depending on the size of the practice and the type of medical records that you keep, ranging from a locked filing cabinet to an entire wing of medical records for a larger institute. The crucial point to remember is to make it as hard as possible for any unauthorized personnel to physically gain access to medical records.
However, it’s important to keep in mind that physical safeguards are only as effective as the number of people that know how to get past them – or in this case, authorized access. Medical practices and institutions should also be careful to not let these physical safeguards affect the efficiency and ease of accessing these medical records, especially when the patient in question is going through different diagnoses and tests.
Physical safeguards also need a system that can help anyone who accesses them to navigate their contents to find the exact medical record that they need, so implementing a comprehensive yet easy-to-understand filing system is a necessity for a practice looking to protect paper records. Any further changes and improvements to physical access can be discussed with your building planner or any contractor assigned to work on your healthcare facility.
An often-overlooked area of storing and securing medical records is the preservation of the records themselves. As physical objects that are handled regularly (or as long as the patient remains within the institute) a paper medical record can go through significant wear and tear before finally being filed away. Even after it’s been properly categorized and indexed, the environment that it settles in can significantly affect the quality of the record as it ages.
While larger medical institutions and practices can afford to seal paper documents in high-tech solutions like vaults, smaller organizations or groups need to make do with implementing a set of best practices to ensure that their paper documents don’t deteriorate with age. These can be included, but not limited to:
Document preservation is especially crucial in practices that contain primary care health records since these are often consulted even late into the patient’s life. Your process should always have a three-fold approach with document preservation: how to file it, how to store it, and how to access it when it's needed. While you can introduce some variation of the practices discussed above, you also need to make sure that the exact storage of these documents is conducive to their state.
Finally, there are occasions where other institutions or the patient may ask for a copy of their medical records. According to the Health Insurance Portability and Accountability Act, your patient is a covered entity that has a legal right to obtain a copy of their medical record whenever they want it, alongside other institutions like other health providers, state and federal governments, and other healthcare organizations. While it may seem like a simple matter to verify the identity of the person requesting the release of medical data, there are strict guidelines (or HIPAA compliance) that you must follow when releasing medical information.
This is because the HIPAA privacy rule offers protections and legal recourse for a patient who’s had their health data mishandled – and any HIPAA violations can severely sanction your medical practice and open you up to lawsuits. To prevent this from happening, practices need to implement official procedures and guidelines to follow regarding the release of medical documents, especially if copies are being made and distributed to other people aside from the patient.
One way to protect yourself from litigation is to always ask if the requesting party has patient authorization to retrieve the medical information they’re asking for and to make a record of everyone who is involved in this transfer of information. Because there’s very little that you can do once you’ve handed over the paper record, making meticulous notes about the people involved in the data transfer can potentially shield you from any lawsuits if the data you released was compromised in some way.
While these steps aren’t the be-all and end-all to making sure a patient’s medical history isn’t compromised, it’s an excellent start for any practice looking to improve its data protection and security against unauthorized access. You can refine or improve on these steps in your own practice if time and budgets allow, but the spirit of these guidelines must be strictly followed.
Paper records can be protected in a variety of ways by a medical practice, but their ultimate flaw – that they’re physical copies of data – can be extremely difficult to solve long-term. To counteract these limitations when it comes to data security, most medical practices and institutions have increasingly switched to electronic record-keeping software and systems, which offer a variety of benefits over manual record-keeping.
There are several advantages that your practice can enjoy once you make the switch to electronic records:
The first significant benefit to switching to an electronic record system is the ease that your staff will be able to enjoy when updating a patient’s chart. In particular, an electronic medical record (or EMR) software effectively digitizes your patient charts, allowing them to be updated in real-time and cross-referenced with other similar electronic records.
This also makes the issue of tracking changes and authorized access much easier to manage, as electronic logs will be automatically generated whenever someone makes a change to the medical record. This improves both the processing of the patient and the quality of their care, as multiple staff members can examine, make changes, and overall monitor the patient without having to worry about jostling each other for room on the record.
For patients that are transferred into or out of your healthcare facility, an electronic health record (or EHR) system is the best way to ensure that every part of their previous and ongoing treatments is properly logged for the departing and incoming medical staff. While the electronic form of this particular health record doesn’t exempt it from HIPAA privacy rules, it becomes easier to both disseminate and track medical records released to requesting parties without having to constantly ask for verification from either them or your client.
This ease of transfer can also help your practice if there are specialists or specific wards in your healthcare facility that a patient will need to cycle through. By keeping an electronic record of their journey through your treatment facilities, your medical staff can easily consult any essential health data between transfers to ensure that everyone is on the same page with the care of your patient.
Finally, an electronic record can make it more difficult for any unauthorized personnel to gain access to medical records while simultaneously keeping them accessible for those who do have authorization. Since you’re not dealing with physical documents that can be changed, altered, or stolen, security becomes easier to manage without having to invest significant time and resources on physical safeguards. By using a platform that guarantees data security while keeping ease of access, you’re better equipped to improve patient confidentiality while keeping your own operations relatively smooth.
With electronic records, you now have access to powerful and useful features such as end-to-end encryption, cloud storage, and multi-layered protection to help safeguard your patient data. And while these protections are certainly robust, they don’t get in the way of any authorized access. This removes the problem of physically locating, unlocking, and withdrawing any physical medical records, with the added versatility and freedom of access from any authorized device.
Of course, you should keep in mind that there will be some hurdles in the implementation of an electronic record system into your practice – and your system will only be as good as the provider that you obtain it from. But a medical practice or institution that can successfully integrate a platform for their medical records is well-equipped to survive the demands of today’s increasingly data-driven world.
Healthcare records are some of the most important pieces of patient data that a health care provider or medical practice can ever handle, and it's your responsibility to use robust security measures and safeguards to make sure that no unauthorized person gains access to patient medical records. By using electronic medical records instead of paper documents, any healthcare organization is better equipped to handle protected health information with confidentiality.
Calysta EMR has extensive experience in providing records management services to any health provider with its EMR software and EHR systems. By using electronic records of patient information, any healthcare provider can improve their patient confidentiality and reduce the likelihood of a data breach for important documents. For more information about how our electronic record systems can help keep a patient's health record safe, contact us today for a consultation.