ROAD TO COMPUTERIZED PATIENT RECORD
 

Dr. G.D. Mogli
 

Invited Guest Article

Introduction :

Healthcare problems have haunted human society since the time immemorial. Social and economic gains of society have direct bearing on the status of the people. Cultural progress depends upon the recognition and elimination of health problems. Health, therefore, is a major ingredient of public welfare. Health is wealth: Good health in any community is possible only when sufficient infrastructure, healthcare facilities and patient care services are ensured.

Despite the fact European and western countries transformed their manual health information management systems including medical records into Information Technology, however, in third world, the dependence on manual recording is still being continued and it is going to stay for some time. It is an imperative to all the health care professionals to be fully acquainted with value and importance of medical record maintenance and their utility in patient care, medical education, research, legal, insurance and third party payments etc. In the process of computerization, the medical and nursing staff have to be aware of the skills of entering information into the computer, brose for the reports and act for the alert messages promptly. The physicians and nurses will play a very important role in completing the information as required by the designed formats and also be able to identify the lacunas, which inhibits to provide complete and appropriate information. The impact of the computers had touched all the fields and unexceptionable to the field of Medicine. The CPR could emerge because of advancement of the computers and communication. A computer-based patient record (CPR) can be defined as an electronic medical record that includes all health information about an individual throughout his or her lifetime, including all care provided at all sites of care in all media. A CPR system includes the process and functionality to allow collection of this information and its integration with knowledge base to create decision support mechanisms, alerts, reminders, and other aids to clinical decision-making. The major value of a CPR is the availability of electronically stored information online for access to the network users.

Role of Medical Records Department in Health Care Institution :

Medical record is an orderly written document encompassing the patient's identification, health history, physical examination findings, laboratory reports, treatment, surgical procedure reports and hospital course. When complete, the record should contain the data to justify investigations, diagnosis, treatment, and length of stay, results of care and future course of action". Thus, it becomes a tool :

To provide a means of communication among physicians, nurses and other allied health care professionals

To provide Continuity of patient care, help in medical education and research

To provide information for the quality review of patient care

To protect legally the physician, patient, hospital and helps in third party payment.

Failure to maintain an accurate, timely and complete medical records means the institution is neglecting the responsibility to patients and the community as a whole. Medical Records are valuable to patients, physicians, nurses, teachers, students, health care institutions, research teams, national and international organizations. As a part of the hospital, Medical Records Department is responsible for proper custody of medical records of patients, for making audits and reports as may be necessary to demonstrate the quality and quantity of work done for assisting in advancement of medical science through accurately recorded data.

Computerized Patient Record (CPR) :

The CPR can also be defined as "electronically maintained repository about an individual's lifetime health (from birth to death) information that includes status and treatment received. The CPR replaces the paper medical record as the primary source of information for healthcare delivery. It is seen as a virtual compilation of health data about a person across a lifetime, including facts, observations, interpretations, plans, actions and outcomes. The CPR is supported by a system that captures, stores, processes, communicates, secures and presents information from multiple incongruent locations as required". Some of major advantages are: convenient, facilitates remote access, health information is more organized and easier to read compared to paper patient record, allows simultaneous access, improve the efficiency of processes such as data collection, data management and data retrieval besides storing of enormous data, analysis and production of outcome with a press of button.

Process of Implementing CPR :

The process of implementing CPR is an art for which a master plan has to be drawn, includes formation of committee, process of decision-making and implementation. The CPR implementation committee has to be formed with the Director of Institution or selected personal as the Chairman and Medical Record Administrator as the Project Coordinator with the following members.

  1. Physicians from Medicine, Surgical, Pediatrics Obstetrics and Gynecology.

  2. Heads of Departments of Radiology, Laboratory, Nursing, and any other depending on the institutions.

  3. Hardware Engineers

  4. System Analyst

  5. System Programmers

A viable CPR to be developed that would meet the needs of health institutions, moreover, it should secure information and protect confidentiality. In order to succeed in that direction the following Systems Analysis and Design Processes have to be adopted which include the following:

SYSTEM ANALYSIS AND DESIGN :

System Analysis and Design is the process of examining the business situation with an aim to improve it to better procedures and methods which includes the following: This is particularly very much relevant in the healthcare field where the developed system is used for patient care with life and death issues.

  1. System Analysis

  2. System Designing

  3. System Programming

  4. System Testing

  5. System Implementation

  6. System Evaluation

  7. System Training

Systems Analysis : is the process of collecting organizing and evaluating facts about information system requirements and the environment in which the system will operate.

System Designing : is the creative, technical process of converting information system requirements into a detailed set of specifications for the new systems. System Designing includes; Forms, Data, and Data flow designing. Hipo Charts are hierarchical Input Process, Output chart. HIPO charts are also graphic diagrams, which are very effective for documenting of system. System security designing is one of the important elements to avoid unauthorized user access as the patient records and information is confidential.

System Programming : is to select appropriate software and hardware in the first step. The software dictate the requirement of the hardware.

System Testing : is the critical process for the program development. The objective of the system testing is to prove that there are no errors in the program. The following are to be included as part of System Testing such as System Objectives, Input forms and procedures, Output Reports 

System Implementation : There are three types of implementation such as: Phase by phase implementation, total implementation and parallel implementation.

System Evaluation : is one of the important tasks to be performed after the implementation phase. There are three types of evaluation, they are: Top-down begins with high level, Middle-out - begins somewhere in the middle of the system and Bottom-up evaluation begins with the detailed modules of the system an proceeds to look at higher level modules of greater aggregation.

System Training : Success of any system is on hands of the end users. As part of CPR implementation, the training to the end users should be given.

ROLE OF HEALTH CARE PROFESSIONALS:

Conventionally, the role of the health care professionals have been mainly to provide patient care services perform research studies and to administer the organization. Hence one has to spend two-third of his time in collecting the manual patient care information to perform the above said functions effectively. The new role, will be quite different in terms of management of patient care. The availability of online health care information and the flexibility of sharing the patient care data can, and to cross-referencing the patient CPR information available globally would strengthen the health care professionals in rendering swift safe and accurate patient care at moderate health care cost. However, the health care professionals have to acquaint themselves with the Information Technology through continuing education on IT to exploit the amenities of the CPR to utilize the health information maximum to provide best possible health care and to control the health care cost that would benefit the nation and achieve the WHO goal of "HEALTH CARE FOR ALL".

SUGGESTIONS :

Although we meticulously approach to develop the CPR, in a very systematic way taking into every possible constraints and consideration to evolve, a friendly user system that would facilitate end users with ease. Despite all efforts, certain issues required to be evaluated and addressed to avoid: later problems such as :

 

Many senior staff are accustomed with the written data, would hesitate to deal with the mouse cursor facing the screen and they may fee uncomfortable to document as most of the patient information are to selected from the available list instead of writing as free text.

The software consultant should not depend on one particular physician exclusively for developing the software.

There is a need to for concurrent checking as it forbids retrospective evaluation.

Sound to be incorporated in MPI to offset various spelling mistakes.

Training to all the staff to be proficient with the operational system.

Besides one-computer maintenance person, one MRD staff with computer programming background required to work as standby.

Hand held computers have to be properly planned, convenient to the users such as physician, surgeons, nurses, paramedics, so that is strain free and end users able to work properly.

It is advisable to have forms content, data-exchange, and vocabulary standards, that are necessary for transmitting complete or partial patient records, and that they are essential to the aggregation of information from many sources, either for longitudinal records for individual patients or for databases of secondary records to be used for research purposes.

Training, educating and validating are on ongoing process. Computer literacy varies in most departments, so plan to train and retrain. Attitude is a major factor in this process. If your staff is excited about the conversion, their attitude will spread to other users, thus enhancing the acceptance of the system. Implementing an information system is a challenge, however, the benefits far outweigh the difficulty of installing it and the great benefactor is the patient.

References :

  1. Role of Health Information for Care for Cost, Quality Assurance - published as poster in 13th International Health Record Congress, October -2000, Australia.

  2. Implementing Paperless Medical Record System- by Dr. G.D. Mogli, IHRIM Journal, March, 03, UK.

  3. Chapter - 9 of Medical Record Organization & Management - Computerization of Medical Record Systems by Dr. G.D. Mogli, Jaypee Medical Publishers, India.

  4. Role of Medical Records in Quality Nursing Services - By Dr G.D. Mogli, Oman Nursing Journal, July 2004.

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