Records Control in Healthcare One

Records Control in Healthcare

One consistent theme that emerges from all of the data taken from large, medium, and small facilities about their records-keeping procedures is that digital record-keeping is the way of the future. Most large-scale facilities have already made the full transition to digital technology. The small facilities that have not shifted to a computerized format tend to handle very few documents a day, less than ten in some cases, and many of them report that they will shift over to electronic record-keeping in the near future, despite their small size. Some also report that computer back-up is used in an unspecified manner for paper data. Even the smallest and most change-resistant of all facilities will likely have to shift to digitalized computer systems, simply because other aspects of the healthcare system do so. Large health insurance agencies and the U.S. government will likely shift to a paperless system in the future to deal with the volume of data available and necessary for the American healthcare system to function and provide quality care.

The swift transfer of patient records requires a computer-based system. Imagine if a patient was critically ill far away from home -- digital technology allows the transfer of complete and critical health information, such as information about patient allergies, medications and past conditions, as well as family information to almost any point of care with Internet access. This simply is not possible with a paper-based format, where data must be transferred in a clumsy, slow fashion by fax or phone.

Paper record-keeping, even when feasible in terms of the amount of information that must be stored, is problematic in terms of storage space and even security, as locked filing cabinets can be conceivably be broken into with greater ease than a password-protected computer system. While the frustrations of a computer system that is frequently 'down' can make an employee long for an old-fashioned 'vertical file' cabinet system, the chances of files being lost or mishandled are likely even greater than in electronic format. Also, electronic files can be in two places at the same time and one of the great difficulties of using a paper-based system is that files may be lost as they circulate throughout the facility. There are still arguments in favor of paper-based systems, however, including the fact that computer-phobic employees will be less prone to make errors. Proper training and increasing comfort with computers in succeeding generations are working to counteract this argument.

The best compromise to anxieties about lost information may be using an electronic format, as most electronic systems have a method of data recovery while paper systems do not. Having paper 'back up' provides a critical third form of insurance for some places of care. This presumably confers the advantages of easy access and searchability in digital format, but there is recourse if the computer system goes 'down.' Since the paper is only used as 'back up' this means that the files are under lock and key, in a centralized location or in the department generating the data. They do not circulate throughout the facility, ensuring a greater chance of misplacement or security compromises. But even in this instance, errors can occur -- timely record-updating and writing times and dates next to new information when it is added to a patient's file is essential, to ensure that there is not a discrepancy between the patient's data kept in two different locations. In fact, one worker at one of the larger facilities expressed dissatisfaction with the paper back-up method: "Keeping everything together either electronically or on paper not both. Causes too much confusion," she or he wrote.

Unfortunately, in large and small facilities, even with security procedures such as password protections for digital data, safety concerns remain. Concerns about compromised patient safety were often expressed by workers and the danger of legal violations for the facility because of lack of compliance with government regulations even if no malfeasance was intended. There were also concerns about misinformation about drugs and patient drug interactions because of incomplete patient data. If data is lost, patient safety can be compromised. Having to recreate a lost file can be difficult when there is insufficient or contradictory back-up information. Also, some facilities do not keep files on former patients, which can be a problem if a patient contracts a condition which requires him or her to find out past information about his or her medical history. Most larger facilities have standardized operating procedures about when medical records are destroyed, such as doing so after every ten or five years, notifying a patient when this takes place, and giving a patient the option to obtain the records if they show an identifying card, but others do not, or do not inform patients of these procedures.