Understanding Medical Records: Benefits, Drawbacks, and the Evolution of Healthcare Information Management

Crucial Role of Medical Records in Healthcare

Medical records serve as a critical tool in healthcare, offering a holistic perspective of a patient's health history. These records provide a comprehensive documentation of past health issues, test results, and medications, enabling healthcare providers to make informed decisions regarding patient care. In the digital age, patients now have increased access to their own records, leading to a new set of challenges and benefits.

The Advent of Electronic Health Records (EHR)

Electronic health records (EHR) have revolutionized the healthcare industry by digitizing patient's paper charts. They collect a patient's history of conditions, tests, and treatments, enhancing the efficiency of medical practices. The American Medical Association (AMA) has been instrumental in reducing the burdens of EHR on physicians, with virtual scribes cutting EHR burdens by 16%. The AMA also advocates at both federal and state levels on key healthcare issues impacting both patients and physicians, including prior authorization. <1>

Importance of Medical Records Retention and HIPAA Compliance

Medical records retention is crucial for tracking patient treatment plans, ensuring quality of care, and dealing with medical malpractice suits, licensing board complaints, and medical billing audits. Several federal and state laws govern the retention of medical records. Best practices include retaining records sent by external physicians, maintaining accurate patient charts, and complying with patient requests for record sharing. HIPAA compliant electronic medical records (EMRs) come with safeguards to ensure connected medical device security. Patients have the right to demand access to their records at any time. Although state regulations may specify a date for record destruction, experts recommend retaining documents indefinitely and only deleting records after the final date permitted by law. Physicians generally cannot refuse to release medical records when patients request them, but should obtain explicit permission for record release to third parties <2>.

The Role of Medical Records in Insurance Claims and Legal Cases

Accurate medical records play a pivotal role in insurance claims and medico-legal cases. The challenges posed by duplicate medical records can be overcome by implementing deduplication using AI/ML technology, streamlining the review process, reducing costs, and improving accuracy <3>. Furthermore, medical documentation is crucial in personal injury claims as it helps establish causation and determine fair compensation. It is used to calculate the actual cost of medical treatment and lost earnings, as well as estimate long-term medical care and future lost earnings <4>.

The Rise of Health Informatics

Health informatics, the application of information and communication technologies to manage medical records and improve patient care, has seen rapid growth. The Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009 spurred this development, aiming to provide better care, improved outcomes, and lower costs. Health informatics provides the foundation to shift healthcare delivery to a value-based system, supporting value-based care approaches and creating new career opportunities. Educational programs, such as the Master of Science in Health Informatics program offered by Northern Kentucky University (NKU), equip students with the skills and knowledge to implement and enhance health informatics systems <5>.

Summary: The Future of Medical Records

In conclusion, medical records, particularly in their digital form, significantly impact the healthcare industry. Despite the challenges they may pose, they also bring about numerous benefits for healthcare providers, patients, insurers, and legal professionals. The future of medical records lies in the further digital advancement and enhancement of health informatics, leading to improvement in patient care and healthcare outcomes. As we navigate this digital evolution, it is paramount to ensure the security, accuracy, and accessibility of these records to all stakeholders involved.