ROAD TO COMPUTERIZED PATIENT RECORD |
|||||||||||||||||
Dr. G.D. Mogl i |
|||||||||||||||||
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
|
|||||||||||||||||
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. |
|||||||||||||||||
|
|||||||||||||||||
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. |
|||||||||||||||||
|
|||||||||||||||||
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 :
|
|||||||||||||||||
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 :
Implementing Paperless Medical Record System- by Dr. G.D. Mogli, IHRIM Journal, March, 03, UK. Chapter - 9 of Medical Record Organization & Management - Computerization of Medical Record Systems by Dr. G.D. Mogli, Jaypee Medical Publishers, India. Role of Medical Records in Quality Nursing Services - By Dr G.D. Mogli, Oman Nursing Journal, July 2004. |
|||||||||||||||||