practice guidelines for managing health information
Managing Nontext Media in Healthcare
THE MOST COMMON type of media used in healthcare prac- tices in the past several decades has been text. Text is comprised of printed words, letters, and numbers translated into informa- tion used for diagnosis and treatment. Today’s healthcare practices have adopted more sophisticated medical equipment that captures data in various nontext for- mats (see sidebar on page 55). This results in information that is processed and viewed using different types of media. The type of nontext data ranges from photo images to more complex files where data must be processed by an application before they can be viewed or used. Managing nontext data creates unique challenges. For example, data stored in equipment can be retained only by keeping
the equipment. This complicates storage and retrieval practices.
Familiar issues surrounding the management of electronic
health information such as version control, retention and destruction, and access and release of information also must be
managed. Legal regulations present further complexities because state and federal retention laws do not directly address
the various types of nontext media, so defining the legal health
record can be daunting.
This practice brief defines a variety of nontext data types found
in healthcare practices today and outlines the operational challenges of managing this data. It also discusses legal and regulatory considerations, including best management practices to
achieve optimal compliance outcomes.
Legal and Regulatory Considerations
Managing and maintaining health information has never been
a simple task. Nontext data identified and defined as part of the
legal health record is considered health information and must
meet the same legal and regulatory requirements.
Core HIM processes and applicable federal and state regulations must be applied to nontext data. As with text, legal considerations and decisions regarding nontext data can affect daily
operational tasks and the success of the healthcare practice.
Ambiguity in the legal realm regarding nontext media can result
in unnecessary legal and regulatory risks.
Key core HIM functions that must be addressed to ensure
compliance are discussed below.
Defining the Designated Record Set and Legal Health Record
cord (EHR) may be new to practices. Defining the designated
record set and legal health record is crucial in determining what
information will be maintained to support the practice’s business and legal record.
Defining these record sets serves to support:
x Patient care
x Billing practices
x Legal purposes
x The practice’s business and legal record
Under HIPAA, the designated record set allows individuals
the right to inspect and obtain a copy, request amendments, set
restrictions, and receive accounting of disclosures of medical
and billing information. The practice must consider whether to
include external nontext data brought into the practice for con-
tinuity of care as part of the designated record set.
Retention and Retrieval
Retention policies for long-term storage and maintenance of
the legal health record vary by state. Nontext data defined as the
legal health record must follow the same retention policy as the
rest of the health record.
Healthcare organizations and providers should maintain records for a period of time sufficient to meet applicable state
statutes of limitations and accreditation requirements, or they
should follow Centers for Medicare and Medicaid Services
guidelines. The records must be kept for whichever period of
time is longer.
Records generated during the care of a minor should be kept
until the patient reaches the age of majority plus the period of
statute of limitations, as indicated by state law. Organizations
should consult with legal counsel to determine appropriate internal retention policies.
Record retrieval requires that records are stored in a way that
provides ease in accessibility and retrievability. Detailed and
accurate indexing will facilitate the retrieval process. However,
proprietary software used by some medical systems may preclude converting nontext media into a format accessible outside
of the original application.
For example, many radiology systems are able to replicate imaging studies onto a CD containing a “viewer” program that allows the end user to open the image file. Without the viewing
program embedded on the CD, the imaging study is inacces-