The sine qua non for quality health delivery is not merely providing safe and sustainable care to the patients but also proper maintenance of records, accessible in the shortest time. If accurate, legible and updated medical records of the patients are not available, it is very difficult for the care providers to decide on the treatment plan.
It is believed that the patient medical record is the main source of information regarding patient care. The medical record is useful whenever evidences are required to protect the service provider on patient care. The consumer forum is mainly dependent on the medical records, whenever there is a medical negligence case filed. This is the only document for the doctors to prove that the patient care was carried out as per protocol, during such disputes. The insurance companies also need an accurate medical record for settlement of claims. Improper/incomplete record keeping may lead to serious consequences to the service provider and the patients. If the records are not maintained, the medical claim could be rejected by insurance companies. Whenever a patient wants to change the service provider, medical record will be handy and helpful for continuity of care. Any hospital will run successfully, only if it has an efficient medical records system in place.
Purpose of medical records
The first and foremost purpose of maintaining medical records is to clearly lay the road map of treatment in order to facilitate a scientific and ‘on the track’ treatment to the patients. As the doctors keep moving from one patient to another, it is not humanly possible to memorise the details of all patients. The latest information, along with the case history of the patient, will enable the service providers to work out midterm changes, if any, and to continue the already laid out treatment plan. This is a good communication tool for referring, treating, visiting doctors and other care providers. This is the only reliable evidence to prove that a systematic care has been provided by the doctor and hospital, in the court of law. The medical records will be useful for taking many health statistics of the hospital for analysis and improvement. These statistical data are not only useful for hospitals but also to government agencies for many applications. These records are also useful for patients’ reference after discharge and helpful to them as a protective tool, in case of any medical negligence. Traditionally, the records were maintained physically but now it is getting migrated to electronic systems.
Benefits of EMR
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Dr J Sivakumaran
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There are several advantages in maintaining electronic medical records in a hospital. EMR can save a lot of space. When the physical files are digitised, it will occupy very less space and the environment is kept clean. Apart from space, since the system is almost paper free, the usage of paper by the hospital, insurance companies and the patients will be negligible, resulting in huge savings on paper. EMR saves lot of time as well. The waiting time for getting a record is totally eliminated. The time taken to retrieve the records in the computer is the only waiting time required. When the clinical data is available for the treating doctors at the click of a button, the decision on treatment could be taken faster. According to a study, one fifth of medical errors are due to the absence of instant access to patient healthcare information. This will be handier, when the patient is sick and not in a position to respond. EMR helps in avoiding contra indicative medicines and repeated tests by different doctors. Every one of the treating team can see the actions and prescriptions of the other by which the communication will be better. EMR can prevent the consequences of the errors arising out of illegible handwriting of the doctors. When a physical medical record file is repeatedly used by a group of care givers, the life of the file will be limited. The EMR system will not have this problem. The EMR system is accessible at a remote location. EMR records could be seen by more than one person at a time. In EMR, the health statistics and other hospital data can be obtained in less time, when compared to the manual system. EMR also improves efficiency and staff productivity. Many quality improvement measures could be taken based on the data captured by this system. This could be used as a managerial tool too.
Concerns of EMR
As against the conventional medical record system, EMR will be expensive. The patients will always have concerns on the privacy of the documents. There are chances for misuse, if anybody wants to do it deliberately. Adoption of the new system by the busy doctors is very slow. Due to this, an assistant needs to be employed for updating records. Here again, chances of transcription error exists. Even if a doctor is familiar with one system, there is no universally accepted system in use. Doctors who visit more than one hospital will find it difficult to adapt to different systems. Now many hospitals are migrating from the physical system to the electronic system. However, as the volume of old records is very high, it is unclear as to how much time it will take to digitise the old records. Until then, the physical records need to be preserved. EMR could be accessed only in electronic environment. Proper storage system is needed for data backup, whose investment cost will be high.
EMR and EHR
An EMR is the electronic form of patients’ information which contains history, demographic details, diagnostic results, medication, treatment and other clinical details and charts. This cannot be updated or edited by the patients or any unauthorised person. EMR is meant for keeping track of all documentations electronically. This has patient data, recognised as a legal record. Different hospitals have different set of records pertaining to the transactions of the patient in that hospital. Electronic health records (EHR) is a new concept catching up in developed countries. EHR will have all the details of EMR as well as additional information. This is a collection of patient data of multiple hospitals. This will give a comprehensive health record of the patient which could be viewed and shared with the authorised patient care team so that better care could be provided. EHR is also an EMR with interoperability. This gives a picture of the total health status of the respective patient. This could be created and established, only if the EMR of various hospitals have technical support for exchange of information. While the ownership of EMR is with the hospitals, the ownership of EHR will be with the patient.
The primary responsibility of generating, updating, preserving and maintaining the medical records rests with the hospitals. But the treating doctor is also equally responsible for the proper documentation and completion of the records in all aspects. Medical record is the only evidence to prove that the doctor and hospital has taken proper care during treatment, in the court of law. Hence in their own interest, doctors need to give importance to medical records. Spending sufficient time in preparing discharge summary and mentioning the steps to be followed in post discharge care is essential. If it is not mentioned, a doctor can be held responsible, in case any complication occurs in the post discharge stage. Patients who wish to get discharged against medical advice (DAMA) also needs to be provided with discharge summary duly mentioning about the patient’s willingness to get under DAMA duly signed by the doctor and the patient or a relative along with the signature of a witness. This will again protect the doctor from future litigation. Doctors normally will have busy schedules and hence may not devote much time for discharge summary. But this is important documents which will safe guard the doctor and the hospital, in case of any litigation. Having centralised medical records system will have better efficiency in traceability and fixing responsibility of the individuals. In decentralised system, chances for loss of information are high.
Retention guidelines
There is no single guideline indicating how long a medical record needs to be preserved by hospitals in India. Some states have guidelines, while some of them do not. Every hospital has customised protocols fo retention of medical records. In general OPD records are kept for three years, while IPD and medico legal records are kept for 10 years in corporate hospitals. This is also in line with Directorate General of Health Services (DGHS) guidelines for Central Government Hospitals vide ref no: 10-3/68-MH dated 31-8-68. In case a court case is pending on a record, the above rule does not apply. The records need to be preserved beyond the stipulated time period. To allow the possibilities of any appeal, the records need to be kept at least two years after the latest court decision. The Medical Council (MCI) of India has given guidelines that individual doctors should maintain the in-patient records for three years from the date of commencement of treatment (1.3.1). It also guides to make documents available to patients or authorised person within 72 hours (1.3.2). The Consumer Protection act 1986 fixes a time limit of two to three years for filing a suit, from the date of treatment. This period may get relaxed by the court, in an appropriate case. Paediatric patients can file for a medical negligence even after attaining majority. Hence, it is for the hospitals and treating doctors to form a team and take the responsibility of generating, using, maintaining, preserving and disposing of the medical records as per the pre-defined guide lines.
References:
1. Medical records and issues in negligence, Joseph Thomas, Indian J Urol. 2009 Jul-Sep; 25(3): 384–388.
2. Code of Ethics Regulations, 2002, New Delhi, dated 11th March, 2002, Medical Council of India.
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