It has been many years since I acknowledged patient record subpoenas for medical malpractice lawsuits and other legal actions as an HIM professional and designated custodian of records (COR). But the process was memorable.
During the 1970s, one was not able to reproduce analog paper and photographic film or send records by postal mail or courier to the courts. Rudimentary paper and film photocopy machines only recently were introduced into healthcare organizations, and the courts required the personal delivery of “original” source documents and records by a COR. Consequently, upon receiving patient record subpoenas, I took a large cardboard box and collected from each department the “original” source documents required by the subpoenas. The contents included the patient’s paper financial and medical records. The medical records also included all film-based diagnostic images, tape-based medical dictation, cine-based ECGs, and pathology slides.
During the 1980s, when I established my related career in HIT and because of my COR experiences during the “analog” years, I knew well that electronic patient records consisted of more than just the structured data typically found in electronic patient financial and medical records. (Structured data are the record’s binary, discrete, and computer-readable data elements that, typically, are stored in relational databases with predefined fields.) Electronic medical records (EMRs) also consisted of digital diagnostic images, audio file-based dictation, and ECG waveforms. In fact, such unstructured data make up at least 75% of all the data in a typical patient’s EMR. (Unstructured data are the record’s non-binary, non-discrete, and often human-readable data elements that, typically, are contained in text-based reports, emails, and web pages and include symbols, images, video clips and audio clips. In some vertical markets, unstructured data are referred to as a record’s intellectual substance or content. In technical arenas, unstructured data are referred to as “objects”.)
Just like healthcare organizations, the courts finally have entered the digital age. Today, secured electronic files of “original,” electronic source documents and records as well as “copies” of original, electronic source documents and records are admissible in courts as long as the healthcare organization can substantiate (1) the trustworthiness of the system(s) used to store and retrieve the documents and records; (2) the accuracy of the organization’s records management policies and procedures; and (3) the documents and records were not created (or altered!) just for a court case. (NOTE: Always one must verify the courts’ acceptance of digital records on a state-by-state basis.)
Large cardboard boxes have been replaced by EMR (or other system) features that promote single points of personalized access through which to find and deliver electronic information, applications, and services. As such, in either hybrid or full EMR environments, designated CORs, Release of Information professionals, and even patients—after rigorous authorization and authentication processes—merely click on hyperlinks and instantaneously retrieve “original” electronic source documents and records required by subpoenas or other requesters.
While our industry continues to pursue the best “highways” to securely transmit the documents to and acknowledge receipt from requesters, today’s day-to-day challenges involve the current mechanisms used to transmit unstructured data and the shameful output of structured data generated by most EMR systems.
For example, the transmission of the large and ever-growing number of patient diagnostic images (primarily radiology images), which remain hand-carried or sent by postal mail or courier from hospitals, physicians / groups, specialty (e.g., cancer) centers, etc., to other hospitals, physicians / groups, and specialty centers on CD storage media, is completely unmanageable. Many of the CDs containing (e.g., radiology) diagnostic images cannot be imported into the receiving Radiology PACS due to the way the images were burned into the CDs. Although most of the CDs include the senders’ viewers for measuring, window / leveling, etc., often the CD files arrive corrupted. Frequently the CDs are misfiled and / or lost. Consequently, transmitting diagnostic images on CDs has lead to duplicate testing with more patient exposure to radiation. In addition, when the CDs contain diagnostic images other than radiology images, often the receivers have no corresponding PACS for these other, “ology” images.
Thankfully, popular, standard, inbound (i.e., CD ingestion and electronic receipt of diagnostic images) and outbound (i.e., report and image distribution to referring physicians, referral centers, etc.) image sharing solutions exist. However, most are too expensive for the healthcare provider masses. In addition, few, if any, non-standard image sharing solutions exist, whereby direct connections are established between two or more organizations for readings, consultations, and 2nd opinions and inbound and outbound electronic reports accompany the images.
Also, there is not a healthcare professional that has not experienced the reams of paper output generated by EMR systems because the systems’ structured data are not report-formatted for output. This is one reason why a patient still cannot receive his/her entire patient record from a portal! Not that I promote hard copy printing; however, healthcare providers still must maintain a legal archive from which to generate the electronic document presentation as proof for exception and dispute handling. In other words, providers must have the document presentation for legal purposes and NOT an informational statement or data representation of the document, which, unfortunately, remains common in today’s electronic patient record system output.