[Med-privacy] standards for med. records

[Peter Marshall]

Standards for medical records eyed

                                             A federal panel takes the first
step toward establishing national
                                             guidelines for the format and
content of medical records.

                                             By Tyler Chin, AMNews staff. Aug.
28, 2000. 


                                             A federal advisory panel has set
the groundwork for establishing national format
                                             and data content standards for
medical records, including computer-based patient
                                             records. 

                                             The National Committee on Vital
and Health Statistics did not propose specific
                                             standards for medical records nor
call for standards outright. However, in a report
                                             to the U.S. Dept. of Health and
Human Services, it urged HHS to adopt several
                                             guiding principles as criteria
for developing uniform data standards for patient
                                             records. 

                                             "There is no single ... standards
development organization that has made progress
                                             on patient records, so really our
recommendations [at this time] focus on issues
                                             related to how we can move
forward in this area," said John R. Lumpkin, MD,
                                             MPH, chair of the committee and
director of the Illinois Dept. of Public Health. 

                                             According to the 59-page "Report
on Uniform Data Standards for Patient Medical
                                             Record Information," the lack of
standards severely limits the industry's efforts to
                                             improve care, lower costs and
electronically exchange health data because
                                             physicians and other parties are
using information systems that can't talk to each
                                             other. 

                                             The absence of standards also
produces data that for the most part can't be
                                             compared because the meaning of
data elements varies widely. 

                                             To address those barriers, the
report recommended that the federal government: 

                                                          Consider specific
standards that the committee will forward to HHS within
                                                          the next 18 months.
HHS then will decide whether to adopt them in the
                                                          form of a proposed
rule, solicit public comment and then issue a final rule;
                                                          the process would
take about five years. 
                                                          Participate in and
provide funding to accelerate development of testing and
                                                          early adoption of
standards now being developed. 
                                                          Enact national
privacy and confidentiality legislation and other laws to
                                                          encourage the use
and exchange of electronic information. 
                                                          Accelerate
development and implementation of a health information
                                                          infrastructure,
which would include standards, laws, business practices and
                                                          technologies
facilitating the electronic exchange of health data,
                                                          interoperability
between computer systems, comparability of data, and
                                                          better quality,
accountability and integrity of data. 

                                             Although NCVHS did not
specifically call for patient records standards, it left no
                                             doubt that it supported such a
development. The recommendations "reflect the
                                             belief that significant quality
and cost benefits can be achieved in health care if
                                             clinically specific data are
captured once at the point of care and derivatives of
                                             these data are available for all
legitimate purposes," the report said. 

                                             The committee was required to
submit the report to HHS Secretary Donna Shalala,
                                             PhD, under the Health Insurance
Portability and Accountability Act of 1996.
                                             Although it doesn't require
computerized patient record standards, HIPAA
                                             mandates that NCVHS study and
issue recommendations on possible format and
                                             data content standards for
patient records information. 

                                             If standards are developed and
adopted, they will require physicians to go through
                                             some painful changes, Dr. Lumpkin
acknowledges. However, he says, the changes
                                             would ultimately benefit
physicians. 

                                             "The business of medicine is
helping people stay healthy, helping them get better
                                             when they are sick and helping
them live better if they have a chronic illness," Dr.
                                             Lumpkin says. 

                                             "For the average doctor,
[existing] information systems don't help them do their
                                             job better. The ultimate goal --
and where efficiencies and quality come in -- is
                                             when information systems help
doctors do their job better through decision
                                             support, making the information
they need available to them ... to make the best
                                             decision possible. Once you have
these standards in place, vendors will be able to
                                             produce these systems."