The Medical Record is the informational hub of patient care. The record contains individual service data, discipline specific assessments, methods of treatment and progress to date. The roots of the current day medical record date back to Mesopotamia in 4000 BC where early records were kept on clay tablets. Today, the clinical record provides extensive documentation of all aspects of patient care. It contains the most credible evidence of the overall performance of the hospital and its staff and is presently used by both the Joint Commission on the Accreditation of Hospitals (JCAHO) and the Health Care Financing Agency (HCFA) to assess quality of care.

The New York State Office of Mental Health (NYSOMH) operates 28 psychiatric centers throughout the state, which provide both inpatient and outpatient mental health services. Over time, each OMH facility has developed its own unique medical record process and content. However, the increased focus on performance outcomes and effective treatment methods has highlighted the need for standardized, uniform data. This, coupled with the availability of new technologies, has resulted in the implementation of the computerized record, Orion.

NYSOMH also is facing a record retention problem. Throughout its entire history, dating from the 1860's, OMH and its predecessor agencies have had a consistent policy of retaining patient related clinical records indefinitely. As a result, OMH facilities today have the burden of over 130 years of accumulated case records, which, if shelved, would cover over 21 miles.  These records ranging from the distant to the quite recent past are stored on every psychiatric center campus and at some off-campus leased space locations.

State Archives and Records Administration (SARA), a Division of the NYS Department of Education, is the state agency responsible for preservation of historical artifacts. SARA has agreed to take all pre 1920 medical records (primarily bound volumes - prior to movement to a file format for records). This leaves the 1920 to the present for storage and retention with OMH. Fewer, smaller facilities requiring greater efficiencies in staffing and space utilization, cannot support the proper maintenance of these historical paper records.

The state has implemented a project to microfilm and index a sample of the statewide records. This will reduce storage needs, allow for centralized and therefore more efficient and less labor-intensive retrieval, and assure longer available life of the records.

Microfilm has been selected for the archival medical records due to the following:

• The costs associated with conversion of paper-to-digital images and paper-to-microfilm are directly related to document preparation and document indexing for retrieval, which translate into substantial labor costs.
• Microfilm technology is reliable and is likely to remain available and accessible for sometime into the future unlike other, newer, technologies (i.e., optical disk which requires movement to other media at 5-6 year intervals).
• Microfilm meets the State Archives and Records Administration (SARA’s) standards with an expected life of 128 years.

To access the records once they are filmed, the project includes an indexing component. The Med 88 cards which contain data elements required to search the records will be imaged and provide a database indexing feature to allow for enhanced access to the stored film. This is critical in a project of this size, where over 16,000 rolls of microfilm will be produced.

As a result of this project, OMH will be able to preserve for research purposes a robust, longitudinal sample of over 25% of the state’s mental health medical records.

The Request for Proposals (RFP) for the microfilming and indexing of over 75,000,000 pages was mailed to vendors on December 28, 1998 and proposals received on February 2, 1999. Project completion is scheduled for early 2000, fourteen months after the award of the contract.

For more information or suggestions for content on this page, please contact Medical Records.