The patient’s healthcare record has evolved into the most reliable source of data available to fulfill multiple purposes and functions. As many as 150 end users seek access to a standard medical record. With ever increasing numbers of individuals needing the information in a medical record, the physical condition and location of the record becomes extremely important. Here are some disadvantages of using a manual (non-computerized) paper medical record.
1. Costs of manual medical records
There are several types of costs associated with manual patient records. One type, duplication of the record, requires paper and copying supplies, as well as the staff to create and distribute the copies. Staff hired to assemble, file, retrieve, or distribute the hard copy chart is a costly expense. Storage of the paper record necessitates the use of valuable space that could be better utilized. The records also need to be protected from water, fire, or mishandling of the paper to preserve their physical integrity.
One of the most expensive disadvantages of the paper record is duplicate patient testing required to replace lost or missing test results. Repeating procedures may jeopardize the patient’s health, creating a potential opportunity for an adverse medical event. Duplicate testing wastes scarce medical resources (time, staff, supplies, and equipment) that could be used for other patients. It is a contributing source to the rising costs of health care by generating additional charges to be billed to the patient, insurance company, or other third- party payor.
A related issue pertains to ordering procedures or tests that are either unnecessary or contraindicated. These types of decisions, when based on inadequate information or delayed results, create a potentially harmful situation for the patient and a needless expense for all concerned. Claims submitted for medical errors that could have been prevented with accurate and accessible patient information are issues that are seen with the use of a paper record.
2. Lost productivity from manual medical records
Lost productivity results from various inadequacies of the paper record. This affects multiple departments in a healthcare facility. Searches for misfiled charts waste time. Staff members’ time is required to deliver paper records to a specific location. If the paper record is not readily available, clerical staff responsible for filing documentation may need to make several attempts before the task is completed. Medical errors may be made if the staff make decisions on inadequate information.
There is no ability to sort data fields in a paper record. Staff responsible for reporting mandated data elements to the appropriate organizations must perform a manual review. This is a very labor-intensive process, and inaccuracies can occur.
3. Accessibility of medical records
Of great concern is the lack of access to the record. Only one person at a time may use the chart and the chart has to be in a single location. Staff needing access to the record must wait until it is available for their use. This also contributes to the difficulty of updating the paper record, especially for an active patient’s chart since that chart travels with the patient to each location of care. Delivering documentation by hand to the patient’s temporary location lends itself to the potential for losing or misplacing the records. Delayed access to the chart negatively affects coding, billing, and reimbursement processes.
4. Quality of manual medical records
The issue of quality encompasses the physical record, the documentation, and patient care. There are limitations to the physical quality of the paper record. Paper is fragile and does not last permanently. Normal use of the record may result in torn or stained documents. Also, over the years, ink used to complete documentation can fade. Actual damage resulting from water or fire is another threat to the physical integrity of the paper record.
Quality of the actual documentation varies based on the healthcare provider’s documentation skills and knowledge level. While standardization of the data documentation has improved over the years, not all providers use the same abbreviations, terminology, format, or chart organization. This can result in
incomplete or inaccurate healthcare data collection. Handwritten information may be illegible, creating the potential for errors in patient treatment or medication orders.
5. Fragmentation caused by manual medical records
Fragmentation of the patient’s record occurs as the result of multiple encounters with different healthcare providers. Due to disparate patient documentation and billing systems, there is often minimal or no exchange of information that contributes to compiling a longitudinal medical history for the patient. Each provider or facility has a limited portion of the patient’s overall health information. Some minor communication may be provided between referring and consulting physicians, but only for a specific encounter. The level of fragmentation varies based on several factors. These factors include:
• the patient’s ability to communicate pertinent health information to the provider;
• the ability of the provider to collect information that is accessible to other providers;
• the provider’s ability to directly elicit health information from the patient and any written documentation to create an appropriate treatment plan; and
• the limitations of the patient record system(s) that are being utilized to collect and disseminate information.
A well planned and implemented electronic medical record system should address and/or alleviate many of the general disadvantages of the paper record. This is an immense undertaking that requires an in-depth review of current processes, a detailed strategy for determining the organization’s future needs and goals, an organization’s willingness and ability to make significant changes, and the financial investment to achieve the desired results. It is also a very time-intensive project that demands the utmost dedication and commitment by the entire health system. Patients, providers, and other interested parties could all expect to derive benefits from a properly planned and installed automated system.
Mila Carlson, PhD RN, CLNC, CNLCP, Adoption Rates and Barriers to Implementation of Electronic Health Records In Physician Office Practices in Northwestern Illinois, Dissertation Presented to the Faculty of the School of Health and Public Administration, Warren National University
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