The Metamorphosis of Medical Records
October 2004
Two years ago, 20 staff members in the medical records department at Charlotte (N.C.) Eye, Ear, Nose & Throat Associates shared three computers. Their jobs mostly consisted of pushing paper, so they didn't have much need for further automation.
However, two years of using document imaging technology has changed all that. Now, every desk in the department, which supports 48 providers in nine offices, has a computer-and everyone uses them.
"The staff has gone from clerks who were great detectives to technicians of information," says Catherine Caldwell, director of medical records. "I am so proud of them. It wasn't always a smooth transition, but they hung in there and are much happier with their positions."
Information technology has come to the Charlotte practice's medical records department. However, there is a long way to go before the department becomes paperless. "We still are sitting in a department surrounded by 200,000 charts," Caldwell says. "We will start sending scanned paper charts to storage by the end of the year. Within the next few years, we hope to be using the office space that we now occupy for patient care. We will no longer need so much prime square footage for this department."
I.T. is playing a larger role in the medical records departments of provider organizations large and small. And its presence creates new challenges for health information management professionals, who are the stewards of each patient's legal medical record.
In many hospitals and physician practices today, directors of medical records already are working in hybrid paper/electronic environments. An increasing amount of documentation is being generated in an electronic format. In addition, many providers are using document imaging technology to convert paper records into electronic media.
Many hospitals in recent years have implemented clinical information systems to ensure clinicians on the floors have access to patient data during the treatment process. But while data may be automated on the floors, oftentimes paper continues to rule in the medical records department.
That's because many clinical information systems do not support the creation of a legal medical record, says Linda Kloss, executive vice president and CEO of the American Health Information Management Association, Chicago.
Not all the data in an electronic medical record, such as continuously updated vital signs and other routine patient state indicators, comprise the legal medical record. In general, individual hospitals or delivery systems decide what goes in the legal record while following appropriate state, federal or accreditation requirements.
"The clinical systems support order entry, results reporting and capturing notes, but not the archiving function to preserve the record in a legal form," Kloss notes. "They do not support the post-discharge creation and management of the legal record."
For instance, Good Samaritan Hospital in Vincennes, Ind., in 1999 implemented a clinical documentation information system. The goal of the implementation was not to create a permanent electronic medical record, says Wendy Mangin, director of the medical records department.
Good Samaritan instead was focused on giving physicians fast access to data via electronic charting while a patient was in the hospital. That meant the hospital had online medical records on the floors, but still maintained a legal paper record in the medical records department.
To encourage clinicians to use the online system and keep the hospital from being buried in paper, hospital officials decreed that no printing of patient records would be allowed on the floors. Patient data contained in the clinical information system automatically prints 24 hours after discharge in the medical records department and becomes part of the legal medical record.
I.T. Spotlights
- About Us
- Advertising/Media Kit
- Reprints
- Editorial Calendar
- Contact Us
- Customer Service
- Privacy Statement
©2008 HealthDataManagement and SourceMedia, Inc. All rights reserved.
SourceMedia is an Investcorp company.
Use, duplication, or sale of this service, or data contained herein, is strictly prohibited.
