Mold And Health Information Technology
by Bruce McCoy, Bruce McCoy, Hoagland, Longo, Moran, Dunst & Doukas, LLP, New Brunswick, NJ and John F. McCarthy, Sc.D., C.I.H., President of Environmental Health & Engineering, Inc., Newton, MA
Health care providers have been investigating the application of information technology to improve patient care, as early as the mid 1990s. Some have been motivated by the federal government’s recent focus on the implementation of health information technology as outlined in the 2004 “Framework for Strategic Action.” Others have been moved by a desire to increase the quality of patient care through improved clinician accessibility to a patient’s medical records or by the mounting economic pressures and impracticality of maintaining the stores of medical records in paper form. Whatever the motivation which has led them to embrace the high tech future of health information technologies, institutions and clinicians may find their efforts and investments frustrated by an unexpectedly low tech obstacle: mold contamination.
Health information technology (HIT) refers to “[t]he application of informative processing involving both computer hardware and software that deals with the storage, retrieval, sharing and use of health care information, data and knowledge for communications and decision making. A central component of HIT, is the electronic health record (EHR), which is a patient’s medical record, that is stored electronically and maintained by a health care provider to order prescriptions, tests and to inform clinical decisions. For HIT to provide clinicians with a patient’s full medical picture, as envisioned in the Strategic Framework, it critical that all of the patient’s stored or archived medical records be captured, stored and maintained electronically. And as the provider’s employees or vendors’ employees begin this Herculean task of back scanning historical medical records, there is a strong chance that they will be confronted with mold contaminated documents as a byproduct of persistent damp conditions or significant past water intrusions, such as flooding.
While the specter of mold may be the farthest thing from one’s mind as a facility prepares and implements new information technology policies, health information managers should remain mindful that mold and uncontrolled water intrusions, in general, can directly impact health information management, their patients’ health and an organization’s financial bottom line. This article will discuss the threat of mold contamination and its consequences to health information management, the legal implications and solutions, and remediation strategies.
II. THE RELATIONSHIP BETWEEN MOLD AND MEDICAL RECORD ARCHIVES
Health care institution and clinician storage or archival spaces can be a highly opportune place for mold to grow and propagate, first, because of the very rich organic matter that the paper-based archival materials present and, second, because the environmental conditions often maintained in such spaces would help sustain moisture. Mold or fungi are present in both the outdoor and indoor environments and will thrive in anywhere their basic needs are met. To grow, fungi require proper nutrients, a hospitable temperature and, most importantly, moisture. Unlike plants, fungi cannot produce their own food; instead, they secretes an enzyme that digests material in which the fungi is imbedded and absorbs the released nutrients. Some molds prefer the easily digested starches, gums, and gelatin found in paper coating, whereas others attack and digest the cellulose that comprises paper, causing irreversible weakening and staining of the document.
The temperatures maintained in healthcare institutions and clinical practices will tend to accommodate mold growth. Health care institutions, like other commercial buildings, maintain temperatures between 68-76 degrees Fahrenheit (20-25 C) that is ideal for supporting and sustaining indoor mold growth for a variety of species.
According to the Centers for Disease Control and Prevention (CDC), one of the most influential elements in the growth of mold is moisture. “Substantial indoor mold growth is virtually synonymous with the presence of moisture inside the building’s envelope.” Molds reproduce and spread through the production and release of spores. Molds have been found to rapidly produce a large amount of spores under moist conditions. For example, a 1992 study found that fungus can grow and produce spores within a day under moist conditions and within a week on occasionally wet indoor surfaces. Unfortunately, there are a number of different ways in which water and moisture, in general, can enter and contaminate archival storage spaces.
Water intrusion can result from chronic exposure to conditions that may induce condensation of moisture from the air on various surfaces, including records. These can include poorly designed or operated mechanical systems that cannot provide adequate dehumidification, poor insulation around the exterior of the buildings in which thermal bridging with the surrounding environment may take place, and renovations that may not take into account the specific and unique needs that archival storage areas may require.There are also many ways in which bulk water could be transferred into archival storage areas. This can include:
- Leaking pipes;
- Water release from sprinklers for fire protection;
- Accidental water release from sprinklers;
- Flooding from an exterior source, as dramatically seen in the southern United States from tropical storm Allison and hurricane Katrina
Once moisture enters into an archival storage space, it is important that it be promptly and properly removed before mold begins to grow. Mold is a likely result of water intrusion to record storage areas because the environment tends to sustain elevated moisture conditions. Typically, in such archival spaces there is reduced airflow due to the need to maintain proper thermal conditioning within the space, as well as the tight packing of shelving and materials on the shelves that may restrict air circulation, creating pockets of stagnation and dank areas. In addition, as such archival areas are often located in the basement of buildings, they can be susceptible to flooding from ground or surface water. Consequently, water contaminated records and other materials tend to stay wet for longer periods of time, thereby providing a highly desirable condition for mold growth and propagation.
III. CONSEQUENCE OF MOLD CONTAMINATION
A. Record Deterioration
There are both short term and long term consequences of mold contamination. As stated above, with the right environmental condition, mold can use paper as a food source. According to Barclay Ogden, Head of the Library-Preservation for the University of California-Berkeley, mold will attack the coating on the paper as they are sometimes comprised of starchy material. It may also try to digest the cellulose which are the fibers of which the paper is comprised. The ultimate consequence is the digestion and disintegration of the document. However, this digestion is a relatively slow process and assuming that the document was a favorable food source for the mold and the maintenance of moist conditions, document break down could occur in the span of a year. The more immediate consequences of the contamination is staining or even loss of text. The process of fungi digestion employs certain enzymes. A byproduct of that digestive process has color which can result in significant staining to the document and the obfuscation of the text. In addition, where printing is only attached to the surface coating, short-term mold contamination can result in the loss of text.
B. Liability for Personal Injury
Beyond its impact to archived records, institutions and clinicians who discover mold contaminated records should give strong consideration to the risk of mold exposure, real or perceived, to patients and staff. While the state of science has found a lack of objective evidence establishing a causal connection between exposure to mold and adverse human health effects, there is agreement that exposure to specific molds may induce significant allergic reactions in sensitized people. Furthermore, there remains a scientifically unsupported perception in the general public that mold exposure can lead to a whole host of illnesses and even death. For example, its been reported that New York Presbyterian-Columbia Children’s Hospital is currently facing several lawsuits related to the deaths of 4 children allegedly related to their exposure to Aspergillus detected in low levels in 20 rooms at the hospital from 2001 to 2004. In addition, St. John’s Regional hospital in Oxnard California, may end up spending $26 million in its four year efforts to rid its facility of mold. The mold was allegedly caused by construction defects that allowed moisture and water to invade the hospital. According to Charles Levin of the Ventura County Star, the clean-up efforts have affected at least 131 of the hospital’s 210 patient rooms, five of the 10 coronary care unit rooms, a neonatal intensive care unit, the morgue, showers doctors’ sleeping quarters, a dietary facility, break rooms, nurses’ and administrative offices. St. John’s corporate parent filed suit in 2003 naming 15 defendants, most of whom were originally hired to clean up the mold but resulted in new and more extensive damage to prior unaffected areas of the hospital. So while, bodily injury resulting from mold exposure may be in question, the risks and costs of litigation which may result from a suspected mold exposure is a reality that health care institutions and clinicians cannot ignore.
Generally, a health care institution or clinician, like any other property owner can be held legally responsible for an injury that occurs as a result of exposure from a known or knowable hazardous condition that existed on the property. While property owners can only be held liable for personal injuries resulting from known or knowable hazards existing on the property, owners must remain mindful that the law will require them to take reasonable steps to detect such hazards and protect their patients from such hazards should they exist.
In light of the legal exposure that may follow the discovery of mold contamination, institutions and clinicians should consult with their legal counsel about preparing a policy for the identification and assessment of moisture conditions that can potentially lead to mold growth and exposure in their facilities. Such policies should address the following topics:
- Identifying and reporting water intrusion: This section should provide for routine inspections and investigations by personnel or a vendor for water leaks or reports thereof; the removal, drying or disposal of water damaged materials; notification of extensive water incursion or damage; notification of visible mold growth; and notification of moldy odor.
- Prevention: This section should address the inspection and maintenance schedule for the building exterior envelope, the roof, HVAC system, plumbing, exterior grading and drainage, and areas of prior water intrusion.
- Health or allergy related complaints: The policy should provide for the investigation of all patient and employee complaints relating to allergic reactions and or adverse health effects. This section should discuss the interviewing of the affected persons regarding the symptoms, timing and duration of symptoms, the actions that produced the symptoms, and areas associated with the symptoms. A written record of all interviews should be maintained.
- Remediation: This section should provide a guide which will outline and define differing response levels determined by the size of the impacted area. In this section, providers may want to identify when outside vendors may be necessary to properly assessthe health risks the mold growth contamination may pose and perform remediation. Either a mycologist or industrial hygienist can be employed to identify the mold and risks of adverse human health affects.An industrial hygienist would also be helpful in advising on the proper method of remediation. For example, under certain circumstances, it may be appropriate to remediate a small to moderate area of mold growth without the assistance an of outside vendor. Generally, the need for outside involvement will depend upon, first, the resources available to the provider, and, second, the nature and extent of the mold contamination.
The institution of such policies will help provider fulfill their obligations to protect employees and patients. However, please note that should the provider fail to comply with its own policies, that document may be used by future plaintiffs as evidence of the provider’s failure to act reasonably to investigate, detect and prevent their exposure to mold. Therefore, in drafting such document a provider should also consider consulting with an industrial hygienist so that it can craft a policy that is both effective and reasonable in light of the provider resources.
IV. REMEDIATION OF CONTAMINATED RECORDS
The primary goal when addressing mold contamination is to slow or stop the mold’s growth. Often, the steps taken to improve drying conditions within flooded environments, such as increasing heat in an already moist environment, may actually have the effect of inducing mold to grow faster. Therefore, it is critical that the provider explore and appreciate the range of options available, so that the most effective steps can be taken to control mold growth and appropriately restore archived medical records. The following procedures may be appropriate where the contaminated area remains damp, if the number of affected materials is large, or if contaminated materials remain damp.
- A. Reduction of moisture: The primary factor that limits the growth of mold indoors is lack of moisture. Therefore, it is the primary goal of any remediation strategy to deprive the mold of the moisture and or humidity it needs to flourish. It is imperative that any source of water intrusion, such as condensation on pipes, rainwater from faulty gutters, roof disrepair, and or foundation leaks are identified and properly addressed. In addition, it is important that the environmental conditions be maintained well below 55% relative humidity (RH) in order to control any mold growth. Small-scale drying of damp items can be accomplished by simple procedures: spreading papers on tables; standing books on end and opening them like a fan; interleaving papers with blank newsprint and/or blotters; and using fans to circulate the air and speed drying. If a large area has undergone water damage it is generally more efficient to utilize desiccant de-humidifiers, as they are very effective in rapidly dropping and maintaining humidity at an appropriate level.
- Containment: Exposure to mold has been associated with adverse human health affects in susceptible individuals, such as persons with serious allergies, asthma, respiratory problems or compromised immune systems, including persons on steroid therapy. Contact with affected areas should be avoided by such persons. Therefore, steps should be taken to isolate affected materials to reduce dispersion of mold spores and to protect susceptible people. When addressing moderate to large contaminated areas (equal to or greater than 100 square feet), remediation may involve steps to quarantine the area, such as closing doors, hanging plastic sheeting between affected and unaffected areas; and eliminating circulated air from the affected area to the remainder of the building.
- Freezing of archival materials. If the correct steps cannot be taken to rapidly dry the material, another option is to freeze the archival materials. While this approach will not kill the mold, it will stop the mold from growing and give the provider and its remediation team time and opportunity to properly dry and clean the archived materials. If this option is to be utilized, it is critical that the freezing be performed within the first 48 hours of the wetting of the materials.
- Fungicides and Fungistats: In the past, fungicides and fungistats have been used for control of mold in library, archival and museum collections. Ethylene oxide, a fungicidal fumigant, is effective and reliable in killing most mold and their spores. Recently, the use of such substances has been questioned because of concerns about toxicity and long-term negative affects on the records themselves. However, in cases involving large area of contamination, an outside professional may advise using specialized fungicides legally registered for such use. Some fungicides can even provide residual protection for the treated areas. However, as the long-term affects of these fungicides on the materials are still uncertain, direct application and misting should be avoided except in the absence of other viable options.
Whichever remediation option is choosen, it is important to provide appropriate personal protective equipment to those persons who will be directly responsible for conducting the remediation. Precautions should be taken to ensure that those individuals conducting the remediation do not become exposed to excessive levels of mold spores. At the very least, people who will handle moldy materials should wear N95 respirators, disposable plastic gloves, coveralls and head protection.
Mold contamination presents a very low tech but potent threat to the aspirations of health care institutions pursuing the high tech promise of health information technology. However, in light of this potential threat to document integrity and personal health, providers can take proactive steps to prevent mold and or minimize the impact of mold contamination.
- Control humidity in the document storage area. Environmental conditions should be maintained below 55% relative humidity to control any mold growth.
- Identify any sources of persistent water intrusion. Water intrusion can result from chronic exposure that may induce condensation such as poorly designed or operated mechanical systems that cannot provide adequate dehumidification or poor insulation around the exterior of the building. Consider consulting with an industrial hygienist or mechanical or structural engineer.
- Promptly and properly deal with moisture or bulk water if it enters the environment.
- Consult with legal counsel and or industrial hygienist in the preparation of a policy for the identification and assessment of moist indoor conditions.
- If mold remediation is necessary, make sure that the area for remediation is properly contained.
- Consult with an industrial hygienist to determine what method of remediation is appropriate.
If removed quickly and properly, water intrusions and indoor moisture does not have to lead to mold contamination. Preventive measures and efficient remediation are the keys to prevent the low tech risk of mold contamination from developing into a high tech roadblock.