Corn Milton
National Library of Medicine, National Institutes of Health, Bethesda, MD, USA.
J Am Med Inform Assoc. 2009 Jan-Feb;16(1):1-6. doi: 10.1197/jamia.M2925. Epub 2008 Oct 24.
Retention policies for clinical records are set primarily by the states, although the federal government mandates minimum maintenance periods for certain classes of patients and selected types of information. State policies vary considerably, but most jurisdictions permit many types of data to be destroyed after some period usually shorter than 10 years. Many health care organizations hold records longer than mandated, but over time much clinical data are discarded or become difficult to access. For improved care of patients and for support of research, the nation should recognize that clinical information, both paper and electronic, constitutes a valuable asset, the national phenome, that deserves long-term storage in archives that preserve both the records and access to the information. The technical and social problems of establishing archiving are formidable but offer an opportunity to exploit the potential of clinical information for public good.
临床记录的保留政策主要由各州制定，不过联邦政府规定了某些类别的患者及特定类型信息的最短保存期限。各州政策差异很大，但大多数司法管辖区允许在一段通常短于10年的时间后销毁多种类型的数据。许多医疗保健机构保存记录的时间超过规定期限，但随着时间推移，大量临床数据被丢弃或变得难以获取。为了改善患者护理并支持研究，国家应认识到纸质和电子临床信息构成了一项宝贵资产，即国家表型组，值得长期保存在既能保存记录又能提供信息访问的档案库中。建立存档面临的技术和社会问题艰巨，但也提供了一个为公共利益挖掘临床信息潜力的机会。
