Keeping Better Records
Good record keeping is an essential part of health care and the responsibility of every clinician. Many clinicians feel comfortable with paper-based records but there are a number of disadvantages to paper based systems:
- Ambiguity. Language can be ambiguous, and handwriting can be illegible.
- Transmission. Paper records are difficult to transmit, and methods such as fax are very insecure
- Storage. Paper records are very bulky and vulnerable to damage from wear and tear, fire, water, coffee etc.
- Sorting. Paper records can only be sorted one way at a time, usually alphabetically.
- Searching. Looking for information can be a time consuming business.
- Sharing. In integrated care, paper records leads to incomplete data sharing across multiple agencies and even within teams.
The problems can be most obvious at the interface between parts of the system. Consider discharge from hospital. Discharge summaries can take a while to emerge. Recently, a local hospital told me that they had a target of typing discharge summaries within two weeks. But:
- They had no target for how soon the typed summary would reach the general practitioner.
- They weren’t actually hitting the target.
- Because they recognised this was inadequate, faxes were used to transmit information in a very insecure fashion.
Paper based records may suit the individual health care professional but do not easily follow the patient. Community-based health professionals may be further distanced as information may have to reach them via the general practice introducing a further delay.
Electronic records offer some considerable potential benefits:
- Clarity. Electronic records are precise and legible.
- Transmission. Electronic records are simple to transmit, and provide inbuilt protection methods such as encryption.
- Storage. Electronic records are compact and can be backed up readily to protect from damage from water and tear, fire, water, coffee etc.
- Sorting. Electronic records can be sorted any number of ways.
- Searching. Looking for information is facilitated by the use of structured coding schema and query languages.
- Sharing. In integrated care, electronic records can facilitate data sharing across multiple agencies and even within teams.
However, realising these benefits can be a complex exercise, and electronic records offer their own range of problems:
- Ambiguity. Sometimes the information we wish to store has a degree of inbuilt uncertainty. Electronic records can be inflexible.
- Transmission. The ease of transmission of electronic data can pose a threat to confidentiality and offer potential routes for attack from hackers and computer viruses.
- Storage. Although looking after electronic records is facilitated by the technology, many users don’t do it, leaving records vulnerable.
- Complexity. The technology itself can provide a barrier to the information.
The incentives for individual clinicians to adopt electronic records are less clear than the benefits to patients, hospitals and funders, ie insurance companies or governments.