With the ever-growing population leading to an increasing number of patients every day, hospital staff and doctors find it difficult to maintain medical records on paper. The traditional system of keeping records is not only cumbersome but also has other challenges like:
- Slow: With information being exchanged mainly through calls, fax, or mail, the process of information transfer is prolonged, leading to loss of time, sometimes life for critical patients.
- Lack of unified view: Patient information is scattered across departments like doctor, lab, pharmacy, and hospital, making it difficult to access across departments and doctors. Hence, often doctors and hospitals missed out on relevant information like drug allergies.
- Storage: With a paper-based system, storing all the data is a challenge both in terms of space and cost. Moreover, patients need to carry a physical copy of reports, prescriptions, and their medical history, which is not feasible in case of emergencies.
Thanks to technological advancement, hospitals, and doctors are resorting to maintaining records electronically, which can be accessed both by doctors and patients across any device anytime.
Medical record management involves maintaining all records of a patient throughout their lifecycle from creation, receipt, maintenance, and use to disposal. Medical records include a patient’s history, clinical findings, diagnostic test results, pre- and postoperative care, patient progress, and medications.
While the benefits of maintaining medical records electronically are many, we have listed some of them below:
- Access and storage: Storing documents is cumbersome, both in terms of space and sorting. Electronic medical records not only save space but also makes sorting and search easy with tags and meta tags.
- Cost saving: Setting up the system is costly and involve resources. However, once set up, hospitals and health professionals will need less support to manage, less security to protect, and less space to save – contributing to cost saving.
- Security: Electronic documents are backed up onto multiple systems. Hence the loss of a document is not irreversible like paper documents. Moreover, the files are encrypted, and security access can be set to prevent unauthorized access, making the records more secure.
While it is convenient to maintain health records electronically, doctors and hospitals should consider the following while transferring from paper-based reports to electronic reports:
- Which historical patient information should be available for patient visits during and after the transition?
- What are the best methods of converting this information to the EHR?
- What is the best way to ensure that the converted data and information is of sufficient quality?
- How long should the paper record be available after the conversion?
- How long do paper records need to be kept after the transition to the EHR?
- What is the role of printing and should it be allowed during the transition?
How to convert the data?
While there are multiple methods to convert data, cost and patient safety must be considered while choosing the mode of data entry. For example, drug allergies should be entered manually and not scanned, as scanned documents cannot be cross-referenced.
Depending on the cost, timeframe, type of data, and availability of resources, hospitals and clinics can resort to the following methods to convert the data:
Direct data entry: Items such as allergies, medications, and symptoms are loaded into predetermined data fields, which staffs well-versed in medical terminology enter into the system to ensure minimal error.
Backloading from other systems: Depending on the patient population, available historical information electronically, and final version of the patient information available, transcribed noted can be backloaded into the system.
Document imaging: Although a labor-intensive and expensive process, document imaging is necessary for reports and scans.
EMR in India
While most of the developed countries have already opted for EMR, some challenges for a country with a population like India remain. While most corporate hospitals have already started maintaining EMR, there is a rare exchange of EMRs between the hospitals. Considering most of the population is not technologically advanced and belong to rural areas, India needs a comprehensive EMR system that is easy-to-learn and user-friendly.