Transition from the Paper-Based Patient Record Management to Electronic Based One - Coursework Example

CURTIN HOSPITAL: REPORT ON THE TRANSITION FROM THE PAPER BASED PATIENT RECORD MANAGEMENT TO ELECTRONIC BASED PATIENT RECORD MANAGEMENT ) (Institutional Affiliation) Table of Contents Table of Contents 1 BACKGROUND INFORMATION 2 INTRODUCTION 3 DISCUSSION IN RELATION TO THE EXISTING SYSTEM 3 DISCUSSION OF NEW STANDARDS IN RELATION TO MANAGEMENT OF ELECTRONIC PATIENT INFORMATION 4 HOW THE TRANSITION TO AN ELECTRONIC SCANNED RECORD WILL BE MANAGED 5 OTHER REQUIREMENTS TAKEN INTO CONSIDERATION 6 CONCLUSION 6 REFERENCES 8 BACKGROUND INFORMATION Curtin Hospital is a 300 bed medical facility with very many patients benefiting from its services. The hospital ensures proper management of its patients’ medical records through filing their records and forms in folders. The folders are shelved for future reference on a patient. Whenever a patient comes, his records are sought from the pile of folders to access his medical records. Sometimes the folder may not be located and the patients are forced to fill forms on their medical history and their medication before being attended to. Through this system, it is sometimes hard to avoid some errors including misplacement and loss of patient record. Severally, the error of wrong drug administration been encountered due to confusion brought about by patient record management. INTRODUCTION This report involves the methods of transition from paper based patient record management to electronic patient record management. It also highlights the improvements that come along with the electronic patient record management system and the benefits over the paper based record management. Scanning of forms is a method of transitioning from the paper based patient record management to an electronic patient record management system (Gartee, 2007). Scanning of forms ensures the conversion of the available paper records to electronic form. The electronic patient record management system is a system that ensures correct handling of patient information in order to ensure confidentiality and ease of access of the records by the required personnel. This system also saves on time and effort as opposed to the manual paper management system. The manual paper based patient record management is a system that involves the handling of patient records in paper work. The records are kept in folders and shelved. DISCUSSION IN RELATION TO THE EXISTING SYSTEM For a very long time, Curtin Hospital has so much relied on paper based medical records in carrying out the medical activities. This system might have met the minimum needs of Curtin Hospital, but it has not been the best system, keeping in mind the many errors that have been brought about by this system (Dick, Steen & Detmer, 1997). With the increasing patient confidentiality regulations, it becomes a challenge to maintain the confidentiality of patients especially when dealing with paper based medical records. Patient records have been kept in folders and arranged in shelves. The folders and patient records are easily reachable, and anybody can temper with them or even steal them. Misplacement can also be done in the current system, for example, records of Patient A can easily be mistakenly placed in the folder of Patient B. Generally, there is poor patient record security in the current system. A lot of time is used in trying to locate patient folders in the current system. Curtin Hospital has very many patients whose records are kept in the hospital. Locating their files is a very tedious exercise (Clercq, 2008). Patients are also asked to fill forms of their medical history every time they come for medical care. They also have to fill records of their conditions, medication and previous treatments. This makes the current system not efficient. Generally, the current system deals with piles of paperwork, which makes them prone to errors and loss. They can be torn, lost, misplaced or even exposed to wrong people. It also needs duplicated efforts when dealing with them. DISCUSSION OF NEW STANDARDS IN RELATION TO MANAGEMENT OF ELECTRONIC PATIENT INFORMATION Switching to electronic patient information management system is an action that can be able to solve the problems that come with paper based medical record keeping. With the electronic system, patient information is stored electronically, and record keeping is made efficient. With the electronic method, patient records are kept in an organised manner, easy to retrieve at any time. Unlike the manual paper, record keeping where a lot of time is wasted in trying to locate the records and even record loss is easy, the electronic method makes it easy to retrieve information and reduces the risks of record loss. With the electronic patient information system, the health providers have all the information they require about their patients. Patients don not have to fill forms of their medical history whenever they get to the hospital (Carter, 2001). This will also improve the patient confidence in the quality of service offered in the hospital. Whenever a doctor gets to a patient to attend to him, he already has all the information regarding the patient’s medical history and medication. The electronic system ensures security of patients’ records. Electronically stored records are restricted only to personnel of a certain security clearance, and they have to use their usernames and passwords to access the information. Patient information cannot be accessed by any person. This is so to ensure security and protection of patient information and medical records. This system does away with errors of misplacement of patient information and confusion of medication. It ensures efficiency and reduces a lot of work done on the manual paper system. Allot of cost that was used in the manual paper work system is cut and ensures neatness and space management. It ensures that the medical services offered are quick and accurate (Zaleski, 2009). The employment of the new electronic patient information management system will improve the efficiency, quality of services and medical care offered at Curtin Hospital, besides the cut on cost used on paper based medical record management (Bemmel, 1995). HOW THE TRANSITION TO AN ELECTRONIC SCANNED RECORD WILL BE MANAGED The transition from the paper based management system to the electronic based will be done with professional medical record scanning service. This method is employed because it is very cumbersome to key in all the patient information that is already with the hospital, and it will be very unprofessional to start asking the patients for all the information afresh. The professional medical record scanning service is a tool that is able to convert scanned forms and medical records into electronic forms in any format required. Therefore, all the available records in Curtin Hospital will have to be scanned using this service and stored electronically. This information will then be secured and made accessible to people of certain clearance (Lehmann, 2006). OTHER REQUIREMENTS TAKEN INTO CONSIDERATION The transition to the new electronic system will also require the inclusion of information that is handwritten, barcodes, text boxes, circles, matrices, form numbers and machine typed information. This information will have to be transferred to the electronic system using different scanners. Intelligent Character Recognition (ICR), Optical Character Recognition (OCR) and other scanners like the Bar Code Recognition (BCR) may be used for ensuring that the above information is also converted to electronic system (Ball, 1992). CONCLUSION Curtin Hospital, generally, has been envisaged to move to greater heights of medical care, and to offer better quality services with the employment of the new electronic patient record management system. It has been noted that paper work causes mismanagement of patient information. Misplacement of patient record and even loss is a common problem encountered with dependence on paper work. Security of patient information is also at risk when using the paper based patient record keeping. Several cases of wrong medication were noted due to confusion of the records. The electronic system has been found to be the best method to solve the current issues that come with paper work. It ensures security of patient information and records through clearance level access. It also helps in fast access of patient records when needed and readily available medical history. It enhances efficiency and reduced cost (Andreassen, 1995). The transition will be done by use of professional medical record scanning service. This will be done through form scanning and the use of Intelligent Character Recognition, Optical Character Recognition and Bar Code Recognition scanners. The transition to this system will ensure efficiency in Curtin Hospital. REFERENCES 1. Andreassen, S. (1995). The Computer-based patient record. Baltimore, Md.: International Medical Informatics Association. 2. Ball, M. J. (1992). Aspects of the computer-based patient record. New York: Springer-Verlag. 3. Bemmel, J. H. (1995). Yearbook of medical informatics 95: the computer-based patient record. Stuttgart: Schattauer Verlag. 4. Carter, J. H. (2001). Electronic medical records: a guide for clinicians and administrators. Philadelphia: American College of Physicians-American Society of Internal Medicine. 5. Clercq, E. (2008). Collaborative patient centered ehealth proceedings of the HIT@HealthCare 2008 joint event: 25th MIC Congress, 3rd International Congress Sixi, Special ISV-NVKVV Event, 8th Belgian eHealth Symposium. Amsterdam: IOS Press. 6. Computer-based patient record implementation issues. (1994). Frederick, MD: Aspen. 7. Dick, R. S., Steen, E. B., & Detmer, D. E. (1997). The computer-based patient records an essential technology for health care (Rev. Ed.). Washington, D.C.: National Academy Press. 8. Gartee, R. (2007). Electronic health records: understanding and using computerized medical records. Upper Saddle River, N.J.: Pearson Prentice Hall. 9. Lehmann, H. P. (2006). Aspects of electronic health record systems (2nd Ed.). New York: Springer. 10. Zaleski, J. (2009). Integrating device data into the electronic medical record a developers guide to design and a practitioners guide to application. Erlangen: Publicis Pub. Read More