Sunday Health Perspective: Patient medical records, Paper based or paperless approach?
By Ibrahim Abdi Mohamed-Phd
Medical records are a combination of self-reported patient information and clinical diagnostic notes traditionally stored on paper-based mediums. In the earlier days, government institutions and entities have been using paper based approach in their communications and documentations. This was the only available mode of engagement of storing and dissemination of information internally and externally. With the advent of information technology, institutions have transitioned to computerized system that is efficient and user friendly.
The global focus on healthcare quality improvement, cost containment and enhanced patient involvement has led to increased need for adoption of Electronic Medical Record systems. This translates to reduced clinician workload and medical errors while saving the institutions recurrent cost.
Electronic Medical records is a computerized system used by doctors to enter pertinent data, including patient demographics, medical histories, consultation notes, allergies, immunizations, vital signs, and prescriptions.
The system is designed to represent data that accurately captures the state of the patient pathways. It allows the entire patient history to be viewed without the need to track down the patient’s previous medical record volume and assists in ensuring data is accurate, appropriate and legible. It reduces the chances of data replication as there is only one modifiable file, which means the file is constantly up to date when viewed later and eliminates the issue of lost forms or paperwork. Due to all the information being in a single file, it makes it much more effective when extracting medical data for the examination of possible trends and long-term changes in the patient.
The governments of developing nations have been compelled to enhance the efficacy and efficiency with which medical treatment is given to their populations in light of the steadily rising costs of healthcare, which are linked to the ageing population and the growth in chronic diseases.
Kenya is globally acclaimed as a leader for its Information Communication Telecommunications (ICT) innovations such as M-PESA. This innovation has not been replicated in the health sector especially the public health institutions that is attributed to behavior change and attitude related which is by design and not by default.
However, with the advent of devolution and the health sector transferred to the Counties, there is need to transition from paper based medical records approach to electronic medical records which is more efficient and effective.
A paper-based approach means slower processes, more administrative resources and higher risk of inefficiency – documents lost, handwritten notes being misread and paperwork incomplete. They’re more at risk of being destroyed in fires, floods or other natural disasters. If this happened, there would be no way to retrieve all of this lost, vital information. Paper records require more personnel to manage and maintain paper files, accesses and organize countless documents.
However, an electronic system means less man power, time and physical storage space are needed Electronic Medical records reduce the incidence of medical error by improving the accuracy and clarity of medical records. Making the health information available, reducing duplication of tests, reducing delays in treatment, and patients well informed to take better decisions.
It’s also easier to retain accountability in electronic health records — each entry log is consistent with a specific individual. This factor makes it easier to keep track of who is diagnosing patients and recommending medical outcomes.
Blessed paperless festive season!
The writer is a Clinician/health systems expert and researcher and currently undertaking Phd program.
He is the former CEC-Health Services, Wajir County Government.
