He's been worrying about it since shortly after the American Recovery and Reinvestment Act allocated billions of dollars for EHRs and he first began to consider the torrents of electronic medical data that will result.
What should be kept? For how long? What storage methods should be used, and will they be vulnerable to technological obsolescence?
How can we ensure that the trove of information locked in the records can be analyzed by researchers without compromising patient privacy?
"I think it's a rich issue and the discussion has just gotten started," Corn says. "I would like it if every hospital and physician's office started giving some thought to what they're going to do."
To that end, he organized a workshop in April, held at the NLM and co-sponsored by the National Institute for Standards and Technology, the Department of Veterans Affairs, and the National Archives and Records Administration.
It attracted more than 90 attendees and identified some basic issues that all providers will have to deal with eventually. (See sidebar, below)
"Our data will change formats and media many times," says Mark Frisse, M.D., professor of biomedical informatics at Vanderbilt University, who spoke at the workshop. "The question is, what's the cost of ownership and what is its real value? Do we need data on every American, or is it better to have really intensive data on 500 people or 1,000? Archivists must make these decisions in the here and now."
Legally, medical record retention requirements haven't changed with the advent of EHRs, and few EHR users have had their systems long enough for the records to have aged beyond statutory limits.
Idiosyncratic
Each state has its own idiosyncratic requirements, often mirroring its statute of limitations for filing malpractice claims. Tennessee requires records to be retained for 10 years after the last patient contact, Virginia for six.
North Carolina has a retention requirement of 11 years for hospitals but none for physician offices. Colorado requires pediatric records to be retained for 10 years after the patient reaches the age of majority.
The cost factor
In any case, state retention requirements are a minimum, and many providers, especially research institutions, are loath to throw anything away when the price of electronic storage is so low. John Halamka, M.D., CIO of Beth Israel Deaconess Medical Center in Boston, calls the cost "insignificant."
BIDMC uses a tiered storage system so that infrequently accessed information can be stored at a lower cost.
Halamka showed workshop attendees a detailed analysis of his data retention costs, which range from 34 cents to 89 cents per gigabyte per year, depending on whether it's replicated and how quickly accessible the information is.
The average per-patient-per-year cost ranges from 5 cents to $1.89, depending on the type of data stored and how quickly it needs to be accessed.
"We save everything forever," says Mary Ann Leach, CIO at Children's Hospital of Denver, which has had a full EHR for about four years and has scanned its paper records so that all information since 2000 is now electronic. "Once we get meaningful use and health information exchange and certification standards put to bed, data retention is next," she adds.
Not only does a pediatric hospital have to save all of its records longer than usual, but many of its patients have chronic conditions and medical records that, were they on paper, would be several inches thick. Add to that a lively research community that never knows exactly what it's going to want, and it's a recipe for massive data accumulation.
Easy to navigate
"The challenge is to maintain it so that it's easy to navigate for the physician," Leach says. "How do we synthesize this data so they know at a glance what's happening?"
Leach says she doesn't think storage media, in themselves, will pose a barrier, even if they have to be swapped periodically due to changing technology. Children's uses a variety of storage media already.
The issue is accountability for the data, protecting it from breaches and inadvertent releases, and managing required releases. "The more records we have, the more we have to manage," she says.
The "keep everything" principle won't be embraced in all hospitals, says Todd Richardson, CIO at Deaconess Health System, Evansville, Ind., which is currently doing a big-picture analysis of its data preservation needs.
Different perspectives
"The people in the CFO's office ask why we need to keep it, and the people at the nurse's station want to have everything and don't see the cost of data storage," he says. His priorities are maximizing the efficiency of storage, minimizing the risk of duplication, and making sure everything can be retrieved as quickly as it needs to be.
"You have to make business decisions without affecting patient care," he says. "At some point information gets stale-what good is a 15-year-old EKG? -but it's not easy to pick what you're going to delete, so we haven't made a concerted effort to purge anything."
An onslaught
Many medical innovations, from 64-slice CT scans to inexpensive gene sequencing, create massive new accumulations of data. Lynn Vogel, CIO of MD Anderson Cancer Center in Houston, is on the front lines of the data onslaught, and presented some of its conundrums at the NLM workshop.
Be the first to comment on this post using the section below.