Safeguarding medical records with digitisation

There has been highly increasing interest with hospitals, clinics and medical fraternity as a whole, to get medical records digitised. The interest has been spurred for several reasons like

  1. Threat from fire and other hazards
  2. Regulatory and accreditation mandate
  3. Space constraints
  4. Research or
  5. Simply make the medical records department (MRD) more organised for better practice.

Whereas some people do understand the intricacies involved in the digitisation of medical records, most people mistake it for just simple scanning of documents and saving it on a computer. While scanning and saving the records are part of the digitisation process, one must note, that there only “small” parts. Simply scanning and saving the records, is only as good as ‘photocopying.’

7 Q’s

For example, if a hospital wants to digitise all its in-patient medical records; then the hospital must ask the following seven questions to the service provider –

  1. What is the modus operandi of scanning the records?
  2. Where and how is the information going to be stored?
  3. How will the records be classified and archived?
  4. Is the retrieval software adapted for hospitals, clinics, doctors and other related entities?
  5. What if the software fails?
  6. Can we generate any reports from the system?
  7. Is it scalable? Can the same system be used to record in other divisions of the hospital?

If the exercise of digitisation is correctly implemented, it leads to incorporation of a systematic electronic medical records (EMR) system – which consists of two major parts such as:

  1. Records of the patient
  2. Details of the patient visit (information on demographics, attending doctor, next of kin, insurance, ailment, etc).

The seven questions, listed above must be answered keeping in mind, the best practices to be followed for both parts of the EMR system.

EMR = Profit Centre

An appropriately done cost-benefit analysis will quickly tell you that an EMR is actually not a cost-centre but a profit centre. There are several reasons –

Systematic Storage: Over time, the centralised system literally reduces the number of papers that go in a patient’s files. Moreover, it leads to standardisation of record keeping – improving operational efficiency. The question “Where is the patient’s file lying?” will never arise.

Quick Search: The records available online, can be located and retrieved in seconds, at the click of a button. So turn-around-time, from actually asking for a particular patient’s medical records, locating it and then finally getting it reduced drastically. It is particularly helpful in medico-legal cases (MLC)

Secure: Apart from becoming damage-proof, once in the EMR system, the medical records never get lost or misplaced. The audit logs can help the hospital to monitor each access to who retrieved the records and when.

Easy sharing: A patient record in an EMR system can be easily viewed by the designated authorised users, concurrently. Apart from that, records can be also be shared with other departments, doctors and patients.

Efficient use of resources: The space and people can be put for better use. In many old hospitals, MRD occupies important space in the premises; downsizing of the MRD has freed-up space to open new departments such as AKD, Cath Lab, etc.

Higher patient loyalty: A cumulative effect of the all the improved processes due to the implementation of the EMR system, transcends not only into better operational efficiency but also enhances the care culture in the hospital, leading to repeat visits of patients.

With a short-term sight, only scan and save option selected due to marginal cost saving by the hospital will not be able to answer all the required needs of the hospital. In fact, in all probability it may turn out be counter-productive. Hospital may later realise the deficit and land up spending twice as much.

Knowledge > Information

What often goes un-noticed, is that an implementation of the EMR system forms a fantastic patient database – where in the patient admission details and medical records are connected to each other. A vast pool of information – that can provide great knowledge to understand the key functional areas in the hospital and their progress. Most hospital information system do contain the patient registration information, but in an isolated manner, which often renders unproductive. When analysed together, the admission information together with medical records, highlights specific parts of healthcare delivery which need attention.

In summary

Hospitals and clinics opting to digitise their medical records should not make a decision in haste, to simply scan the records. Rather they should look to implement the more beneficial EMR system, that will save them time, effort and money in the longer term.

The author can be contacted at info@vidoc.in

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