- Traditionally, these data have been captured on paper source and filed to make what we call patient file. The file keeps growing as patients navigate in the hospital. One would normally have a medical records department where in case an inpatient is discharged, the file is transferred into the medical department for storage.
Medical records are generated daily in out-patient and in-patient departments of every hospital. These include data on demographics, illness investigations and diagnosis.
Traditionally, these data have been captured on paper source and filed to make what we call patient file. The file keeps growing as patients navigate in the hospital. One would normally have a medical records department where in case an inpatient is discharged, the file is transferred into the medical department for storage.
Now imagine this patient comes back after two years with another illness and the attending doctor is interested to have the medical history in the patient file from previous treatments.
The hospital must have a very well and an organised medical records department to be able to retrieve a complete patient file timely. With outpatient department this is even complex.
In rural settings it is common to see patients having an exercise book. A clinician will record in the exercise book and the patient is expected to bring it every time they show up at the facility. This is even more challenging since such records could get lost, or every obscured with spills such as food and drinks.
What if we digitised the records?
Certainly, paper based way of keeping records is challenging for ensuring proper patient care in terms of having a full spectrum of what has been previously done. Records are lost or misplaced.
The advancement of technology and development has indeed provided an avenue whereby things could be improved or done differently.
The use of electronic medical records is increasingly becoming common in routine care across the world. In the developed world this has already become a norm.
In developing countries, such electronic systems were introduced for chronic diseases, such as HIV, and in research and surveillance settings. Still very few centers of excellence would run routine medical record systems.
Electronic medical record systems allow for continuous follow up of patient history and treatment at any time point. It also reduces repetitions of management of patients across different physicians.
This in turn allows proper usage of resources to both patients and healthcare, example, financial resources to medication.
With the electronic medical record system, the hospital management can quickly evaluate the performance of any particular department and act accordingly. The cost that is reduced by introducing electronic medical records is enormous and has been shown to improve productivity among healthcare workers.
However, electronic medical record systems are not without challenges. First, the initial investment both in terms of infrastructure and human resource is huge.
Second, it will need a great deal of training before optimal benefits can be realised.
Third, the need for security systems for data cannot be overemphasised. Use of electronic record systems should not provide a loophole for unethical use of patient information or breach of confidentiality.
Indeed, reforms in healthcare system must include how we collect data and store records in and within our healthcare system. Use of electronic medical records systems is no longer a far-fetched idea rather a reality that must be lived.
A number of open source medical record system have been developed and available for use, for example, the OpenMRS system which is a free software developed to address medical records challenges especially in developing countries and can be customised to a client’s needs.
As we move towards ambitious goals of improving healthcare in our countries, how we collect, manage and store data will remain pertinent to realising such goals. Indeed, the future is electronic and that ‘future’ already lives among us.