Establishing A Connection

It is estimated that more than 90 percent of all information created and used in organizations today is electronic. While the current rate of electronic health record (EHR) adoption may lower this figure in some health care organizations, the trend is clearly toward an increase in electronic information. The requirement to better manage electronic health information and the dearth of management strategies to help the health care industry meet demands such as e-discovery and compliance has highlighted the need for an overarching strategy to aggressively manage records and content.

Many health care organizations are learning the unique challenges associated with managing electronic health information. According to Gartner, "Organizations need to recognize information as a business asset and manage it effectively in order to increase value, reduce risk and improve operational efficiency." Enterprise content and records management (ECRM) strategies applied to health records, health information and organizational information provide value to the entire enterprise by facilitating the location and use of information and effectively managing it throughout its life cycle.

Business drivers for ECRM in health care organizations include the following functions:

The facilitation of patient care and associated processes is a common driver for ECRM in health care. Clinicians are concerned with the vast amounts of information they must sift through to render patient care.

ECRM initiatives respond to the need to organize this vast amount of information so that it can be accessed easily during the patient care process. In this way, ECRM supports patient safety and quality of care.

However, its application is not limited to direct patient health information. It may also be applied to policies and procedures, workflow processes and business documents such as contracts and directories that support patient care and the organization’s business needs.

Health care organizations must ensure compliance with a plethora of legal and regulatory mandates, including those related to billing, state licensures and certifications and federal and state privacy and security regulations. They also must be able to appropriately locate and access information to compile a complete legal health record. In light of the prospect of e-discovery, the growth of unstructured content and its potential loss if not properly managed contribute to risk and legal exposure.

The appropriate application of ECRM strategies and tools is critical in mitigating these risks. In the absence of ECRM, an organization’s ability to collect, review and preserve electronically stored information can be onerous and costly.

Effective record control policies and procedures regarding retention and disposal requirements can reduce costs associated with e-discovery by decreasing the amount of information that needs to be retrieved if records are appropriately destroyed at the termination of their required retention period. These policies and procedures also can reduce the cost associated with restoration of content maintained on media that is difficult to reproduce or that has become obsolete. An organization’s failure to produce relevant requested electronically stored data can potentially result in significant fines or sanctions.

When components of an EHR are housed in various systems, viewing a patient’s complete health record can be difficult, and an inability to present complete and current information can pose a patient safety issue. Accreditation and regulatory bodies may have standards that address this issue.

Accredited organizations must have processes in place to effectively manage information, including its capture, reporting, processing, storing, retrieving, disseminating and display of clinical/service and nonclinical data and information. In addition, the health care organization is required to have a complete and accurate health record for each patient assessed, cared for, treated or served. ECRM is an important strategy for complying with information management and health record standards and regulations.

ECRM involves identifying the organization’s mission-critical records and content and planning for management during manmade or natural disasters, making it a critical part of business continuity planning.

The record life cycle is the foundation of ECRM principles. The following stages of a record’s life cycle explore the elements and common components of records management:

This phase includes creating, editing and reviewing work in process as well as capture of content (e.g., through document imaging technology) or receipt of content (e.g., through a health information exchange).

Every organization must establish business rules for determining when content or documents become records. For example, a clinical document must be authenticated or signed to be considered a record and diagnostic results designated as "preliminary" are not a record until they are designated as "final."

Examples of content not considered to be records are initial versions of a document; preliminary results, drafts and working documents; and informal communications.

Once records are created they must be maintained in such a way that they are accessible and retrievable. Components of this phase include functions, rules and protocols for indexing, searching, retrieving, processing, routing and distributing.

Classification is a critical component of records management. Though not a unique point in the life cycle, it does support the other phases. Record classification creates categories or groups of records necessary for access, search, retrieval, retention and disposition of records.

Metadata are generated at various points in the records management life cycle, providing underlying data to describe the document, specify access controls and rights, provide retention and disposition instructions and maintain the record history.

Controls and audits support a variety of phases in the record life cycle. Functions and processes in this component of records management may include edit checks at the data level, decision support tools, identification of classes of records that require auditing and checks for record completeness.

Preservation is synonymous with storage. Issues associated with preservation include technology and media obsolescence, media degradation, media in an archival system, conversion over time and conversion of standards over time. Closely associated with preservation is retention or the identification of times after which records and content will not be kept and are subject to destruction.

Planning for preservation and retention also should include strategies to identify and prevent modification or destruction of records that are needed for legal purposes or so-called legal hold. Record disposal encompasses the destruction process for data and records including the various media type and documentation of destruction.

This text is an edited version of "Enterprise Content and Record Management for Health care," which appeared in the October 2008 Journal of AHIMA.