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, amednews 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."