Health records in electronic form are the only truly portable and shareable (interoperable, in government-speak) compilation of your health care history available to all of your healthcare professionals! Gone are the copying and postage charges associated with paper copies. All a healthcare business needs to do is make appropriate electronic health file formats that meet your needs available in a network-accessible location like your Electronic Health Record (EHR).
You can access and download the health files over the internet in the privacy of your home or download them using a smartphone app while at the healthcare business. While healthcare businesses are “encouraged” and “incentivized” to make electronic health files available in electronic format, they are not obligated to do so under present laws. This means you must ask for access to most of the health records guaranteed under HIPAA. Access to the health records not in your Electronic Health Records (EHRs) often requires 30 days notice, a written request, and even a face-to-face visit with medical records personnel.
Before you can ask your healthcare provider or a hospital for specific health records, you need to know WHAT to ask for. Under HIPAA (Federal Regulation, 45 CFR 164.524), you have the right to
“access health records in a specific form and format maintained in your designated record set.; or, if not, in a readable hard copy form or such other form and format as agreed to by the covered entity and the individual. If the request is for a specific electronic format, then the covered entity must comply, as long as the information is readily reproducible in that format; or, if not, in a readable electronic form and format as agreed to by the covered entity and the individual.”
In this blog post, we will look at what specific form and format actually means when talking about health records. As shown in my earlier blog post, your health records are actually a collection of files–text documents, images, audio files, and video files that can be read, evaluated, organized, shared, and stored for future use. Form means either paper or electronic media and format means the way that electronic information is encoded for storage as a computer file on your computer’s hard drive, on a removable/portable digital memory medium, or on “the cloud” (in a remote server over the internet).
Let me discuss a quick note about form. All “paper” and electronic copies are not created equal. Just like one “paper” copy can be better than another, so it is with various electronic copies. The copies you receive much meet your needs. For example, if you ask for a copy of an x-ray image (or any other source clinical (“raw”) image), it is a common practice today to give you a CD containing a pre-packaged reader housing the x-ray. This reader is a restrictive program that limits your access to the x-ray image file. You can print and view the x-ray, but saving the actual image onto your computer in its original format had been disabled. I am not a healthcare professional and do not need to view or produce a printed copy of my x-ray image, but I do need to electronically store the copy of the original image file for coordination of care and second opinion consultations with other healthcare professionals. This CD does not serve my need or the needs of the other healthcare professionals with whom I might share the file. This is an example of why it is critical that requests for electronic health records be format-specific.
What electronic health file formats does one request? Let us review a bit of electronic file format basics before we answer this question.
Electronic (Digital) File Types 101
Electronic health files are created and saved in a large number of different formats. In most industries (except healthcare), electronic files are commonly called digital files. The two names refer to the same files. Electronic files are identified by the basic format:
You are probably familiar with many electronic file types already if you have written a letter on a computer, taken a digital picture with your phone, or downloaded a video. The information found in electronic files falls in three major categories; namely, text, visual, and sound file formats. These formats have been created to service various specific needs. In the discussion below, you will see that there are multiple file formats that can be used to distribute the Protected Health Information (PHI) found in your designated record sets. The file format you need is determined by your intended use of the information.
Document (Text) file Formats
The document file is one of the simplest ways to share and store information. The common text file formats include TXT (txt file extension), DOC (doc or docx file extension), and PDF (pdf file extension). For example, if you are using a program to create a text document (like a letter, notes, or a report), you could have files that look like the following:
Unlike the DOC and PDF formats, the TXT format does not allow for images to be inserted into the document. You will never see a TXT or DOC file in your Electronic Health Record (EHR) because they are editable files and healthcare businesses have no reason to provide their health records in this format. The PDF format is commonly used to package information from your designated record sets because it is not readily editable and can be compressed to a small file size. Today, the only health information in my Electronic Health Records (EHRs) has been packaged into PDF files.
Image file Formats
If the PDF file includes images (like x-ray images), then why do we need image files? The PDF file compresses the information within the image in a way that is great for downloading off the Internet, but lousy for fine detail viewing needed for making accurate diagnoses. This is especially critical if you are taking your files for a second opinion.
File formats that have been specifically created for images are numerous and include JPEG (jpg file extension), TIFF (tif file extension), GIF (gif file extension), PNG (png file extension), and BMP (bmp file extension). Each of these image file formats differ slightly from one another and some are better in some applications than others are. For example, the best images for viewing online are JPEG, PNG, or GIF. Most of the images in this blog are JPEGs.
The healthcare industry has unique file formats that have been specifically created for its use. Medical images are called source clinical (“raw”) data and originate from medical equipment (the source). They include x-rays, CT scans, MRIs, and ultrasounds and typically are saved as DICOM (Digital Imaging and Communications in Medicine) images. The DICOM file format has a file extension of dcm. These healthcare-specific DICOM images differ from the more familiar image file formats given above in that the DICOM image includes a text “header”. This header contains the patient’s name, the date, and specific information about the image. For example, a CT scan is comprised of many x-ray images taken from different angles to produce virtual slices of a specific area. The output is a bunch of dcm files and the “headers” identify details about each image in the series. The same xray of an arm is given below in different image file formats.
While the DICOM format is the standard for radiology (negative) images, many of the image formats in widespread use are also making their way into the healthcare industry.
In order to view the standard image files, you need to have an image (graphics) software program. There are many free downloadable programs on the Internet that will allow you to do so. As sharing of electronic health records increases, free software for viewing healthcare-specific file types (like DICOM images) and for converting DICOM into standard image formats (like JPEG) has become widely available.
If you are simply accumulating image files for your Personal Health Record (PHR), then you do not need software to view your medical images. When you make your saved image files available to health professionals for coordination of care or second opinion consultations, they will most certainly have the appropriate software to view the files. You are not expected to be able to analyze these source clinical (“raw”) data files since only qualified medical professionals have the expertise to do so. It is only important that copies of the original source clinical (” raw”) data files be available to you in a format the other healthcare professionals can use. Otherwise, the test will have to be retaken resulting in unnecessary duplication and increased healthcare costs.
Video and Audio file Formats
Video and audio files have evolved greatly over the years and therefore file extensions are numerous. Standard video file formats include AVI (avi file extension), MPEG (mp4 + many more file extensions), Quick Time (mov file extension) , and Flash Video (flv file extension). The video file formats store both video data and audio data. Because video files are large, they are almost always stored in compressed form to reduce the file size. Some compressed forms are better than others for maintaining the quality of the original data.
Videos in the healthcare industry are common. Various medical procedures like arthroscopy, bronchoscopy, colonoscopy, cystoscopy, endoscopy, gastroscopy, laparoscopy, and microscopic surgery are performed using equipment with video camera outputs. Software typically allows for video capturing in DICOM, AVI, and MPEG formats.
Audio file formats are WAV (wav file extension) and MPEG-4 Audio (mp4a + many more file extensions). In the healthcare industry, digital sound files can be used to discover abnormalities in heart beats, etc.
Future of Electronic Health File Formats
Healthcare industry-specific file formats were designed before the HITECH Act of 2009 made “interoperability” (share-ability) a goal for all electronic health records. Medical equipment manufacturers, medical software companies, hospitals, and other healthcare service businesses are working together to update and standardize health record file formats for both patient “engagement” and coordination of care. Because health file formats are evolving and numerous (especially for video and audio files), it is not always easy to be specific when asking for copies of your electronic files. If you do not know the specific file formats for images, videos, or audio files that are readily available, you might ask (usually in writing) more generally for “whatever electronic copy is currently available” in the business’s Electronic Medical Record (EMR) system used by the healthcare professional”,
The Bottom Line
It is important for you to understand that your rights under HIPAA to “access health records in a specific form and format” demands that you know what form and format mean! Form means paper or electronic and format means the way that the information is encoded for storage in a computer file. All electronic files have the basic format: file name.file extension. The file extension tells you what the format is.
The information found in electronic health record files falls into three major categories; namely, document (text), visual (images and videos), and sound (audio recordings). There are multiple electronic file formats in each category for servicing specific needs. The electronic health file formats you need will be determined by your intended use of the information. If you want to keep a record of your original designated record set(s) for coordination of care or for second opinion consultation, you will have to collect the information in file formats that can be used by other healthcare professionals across the country. This means that images, videos and audio files must be electronic copies. If you do not know the exact electronic health file format you need, I would recommend that you ask for “whatever electronic copy is currently available in the Electronic Medical Record (EMR) system used by the healthcare business”. Be prepared for healthcare business resistance when requesting your health records.
You do not have to be able to open or view all the electronic medical files you collect. Healthcare professionals, who have the expertise to interpret the files, will have appropriate software necessary to do so.