Health Records

Paper to Paperless

Health Records

Paper to Paperless

GD Mogli PhD MBA FHRIM (UK) FAHIMA (USA) Visiting Professor, Medical Informatics Mahatma Gandhi Institute of Medical Sciences Sevagram, Maharashtra, India Ex-WHO Consultant and Senior Consultant Health Management, HEARTCOM (USA) Dean, Health Information Management Program Ministry of Health Oman Associate Professor, Health Information Management Degree Program King Faisal University, Saudi Arabia Head, Department of Medical Record Technology Program, Kuwait Institute of Health Sciences, Kuwait Head of Department, Bachelor of Medical Recored Science University of Madras, Chennai, India Consultant/Advisor to the Ministries of Health India, Afghanistan, Iran, Kuwait, Saudi Arabia, Oman, Bahrain, Qatar and UAE

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Jaypee Brothers Medical Publishers (P) Ltd Bhotahity, Kathmandu, Nepal Phone: +977-9741283608 Email: [email protected] Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2015, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Health Records: Paper To Paperless First Edition: 2015 ISBN 978-93-5152-427-4 Printed at Repro India Limited

Dedicated to My adored motherland India and My family for their constant support To my beloved wife Vijaya Mogli, who has been a tremendous support and help in my entire career, serving in nine diverse nations with unusual passion that led to devote maximum time for profession, which I cherished immensely. Obviously, it became a herculean task for my wife to devote best of her time in managing both, kids and all the household issues. To our son Sudish K Mogli, a Senior Software Engineer working for CISCO, California, USA, his wife Archana Mogli who is also a Software Engineer working for HP Company, California, USA, and to our daughter Dr Preeti Sampathy, who is a Dental Surgeon, currently working in Siva Sivani School as an Administrator and her husband Dr Neeraj Kumar Sampathy, who is a Medical Doctor working in the same school as a correspondent and managing their own school, and to our grandchildren, Suraj, Aditya, Riya and Laya.

Preface It is said that the history of medical records runs parallel with the history of medicine. In the growth of scientific medicine, medical records have played an important role as a tool and as a basis for planning patient care. They provide a means of communication between the doctor and other professional groups contributing to the patient’s care, furnish documentary evidence of the course of illness and treatment and serve as a basis for review, study and evaluation of medical care rendered. In most of the developed and technologically advanced countries, realization of the importance of medical records has resulted in the efficient organization of medical record departments and the training of personnel. The medical record trained-personnel are vital members of the health team and their services are used mainly in hospitals, clinics, health departments, data processing units, biostatistical, ambulatory care centers, rehabilitation facilities and medical research programs. To keep pace with the constant growth of medical sciences for the effective healthcare delivery, the demands of trained personnel arise. Without facts, a proper concept and appreciation of health problems, time, effort and funds cannot be expanded efficiently. Obtaining correct data concerning patients, their general health and other hospital needs entail much paperwork, which is often considered as humdrum by physicians and others with limited vision concerning their local responsibilities. The hospital is built and maintained for the benefit of the patients. Failure to maintain comprehensive and accurate records may mean failure in one’s duty to the patient and, thus, ultimately to the patient’s family, community and general public. Consequent to the advent of information technology, the entire world and healthcare institutions are shifting from manual to electronic records. There is no book or any other media that will provide assistance in converting paper-based records into paperless. The author had felt that the dire need of present day is the implementation of electronic health records. Keeping this point of view in mind, this book has been prepared mainly to help the

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existing hospitals, which are already in the process of maintaining hybrid records, and the hospitals, which are going to transform from manual to electronic will find this book immensely useful. The new hospitals, which are going to be established in the future, will also find this book incredible as they would prefer to have only electronic health record system and eHealth management. The book on Health Records: Paper to Paperless is written with the objective to serve the people who are concerned with the direct and indirect patient care, allied and health-related professionals. As you may be aware, hardly there is any book on medical records at par with international standards. In the last few years, the entire world is in the process of conversion of manual records into electronic due to the advent of technology. Although information technology has changed the lifestyle of many, most of the public services have benefitted tremendously by embracing the technology. Nevertheless, the health field due to various issues, such as cost, privacy, confidentiality, and security of information has been slow in implementation. Having realized the immense role it can play in swift, safe, improved quality care, and that it can bring down the cost gradually, many nations have embarked upon shifting to electronic health records and started scheduling the period for complete electronic health records. This is a nightmare for planners to implement the system in a determined period because not only heavy finance is involved but also the right network, hardware, and software systems are to be selected. Another most important issue is what would happen to the huge manual records that have accumulated in the past years. Maintaining manual and electronic records side-by-side will be a herculean task that would bring problems and confusions. I have served in many countries and having my ‘hand on this type of project’ at national and international levels, felt the dire need of a book that could take care of managing manual medical record system as well as the hybrid system that means manual and electronic records maintained side-by-side and gradually implementing complete electronic health records. This book mainly comprises of three parts. Part one is related to manual medical record systems. Part two deals with hybrid records, that is maintaining manual and electronic records sideby-side. Part three deals with implementing electronic medical records.

Preface

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The first part explains the role of medical records and its development, policies, standards, systems, and procedures. The second part explains the hybrid transformation of medical records to electronic records and also explains about the central medical record archives training and research department (CMRATRD), which maintains manual records and the third part is devoted as to how to computerize medical records, electronic health records (EHR) strategic plan, challenges, limitations, functional requirements, and implementation of EHR. This book will be of immense value to the medical record personnel, medical, nursing and paramedics, software personnel to develop healthcare software, medicolegal personnel, etc. The organizers of medical record departments, health directorates, ministries of health and healthcare-involved software companies besides medical record educational and paramedical courses and research institutions will also be immensely benefitted by this masterpiece. GD Mogli

Acknowledgments At the outset, my grateful thanks to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India for bringing out this invaluable book. My sincere gratitude to the state health ministers, deputy ministers and professional colleagues of India, Afghanistan, Kuwait, Kingdom of Saudi Arabia, Sultanate of Oman, Bahrain, Qatar, and United Arab Emirates, for their encouragement and cooperation. My special thanks to Mr Ramalingam Selva Kumar, MA, MS, BMRSc, PGDHM, AHRIM (UK), CHRIM (UK). Currently working as a Clinical Coder, Aberdeen Royal Infirmary Hospital, Aberdeen Scotland, United Kingdom. He formerly worked as a Medical Records Officer, Riyadh, Central Hospital, Riyadh, Kingdom of Saudi Arabia. Mr Narendar Sampath, MA, BMRSc, PGDCS, CHRIM (UK), Medical Record Manager, Welcare Hospital, Dubai, UAE. Mrs Marie Stella Alexander, BSc, BMRSc, CHRIM (UK). Presently working as Medical Records Manager, Hamad General Hospital, Doha, Qatar. She formerly served as Medical Records Officer in the State of Kuwait and Kingdom of Saudi Arabia. Ms Swadhurav, BTech (Biomedical Engineering) working as Research Assistant in Dr Mogli’s Healthcare Management Consultancy, Hyderabad, India. Last but not least, I owe my sincere gratitude to my family.

Contents PART ONE 1. Medical Records ......................................................................... 1 2. Historical Background of Medical Record Administration ........................................................................ 10 3. Development of Medical Records ......................................... 18 4. Medical Record Policies .......................................................... 30 5. Standards for Medical Record Services .............................. 168 6. Medical Record Systems ....................................................... 179 7. Medical Record Procedures.................................................. 200 8. Quality Assurance Standards............................................... 254 PART TWO 9. Hybrid from Manual to Electronic Records ....................... 263 10. Establishment of a Central Medical Record Archives Training and Research Department (CMRATRD) ............ 274 PART THREE 11. Historical Background of Information Technology (IT) .. 285 12. Designing, Developing and Management of Information Technology ....................................................... 291 13. Historical Background of Health Information Technology.............................................................................. 299 14. How to Computerize the Medical Records Management System ............................................................. 307 15. Electronic Health Record ...................................................... 346 16. The Strategic EHR Planning ................................................. 351 17. Challenges of EHR Adoption ............................................... 357 18. Limitations of Electronic Health Records........................... 363 19. EHR Functional Requirements Specifications ................... 368 20. Checklist for Assessing HIM Department Readiness and Planning for the EHR .................................. 375 21. Electronic Health Records Standards.................................. 383 22. Technology Infrastructure Assessment ............................. 391

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Health Records: Paper to Paperless

23. EHR System Implementation and Maintenance .................................................................... 405 24. Standardization of Paperless Health Records ................... 423 25. MRM Professional’s Endurance in the 21st Century ........ 430 26. Tips for Evaluating Electronic Health Record Software .. 440 Terms and definitions ........................................................................ 446 Annexure ............................................................................................477 Bibliography ....................................................................................... 479 Index ...................................................................................................487

Part One CHAPTER 1

Medical Records

INTRODUCTION Healthcare problems have been haunting human society from time immemorial. Social and economic gains of any society have direct bearing on the health status of the people. Cultural progress too depends upon the recognition and elimination of health problems. Health, therefore, is a major ingredient of public welfare. Health is wealth. In a welfare status, health of the citizens is given paramount importance. Good health of our community is possible only when adequate infrastructural health facilities and medical care service are ensured. This entails the provision of necessary educational and research opportunities in medical field and treatment and service facilities. Well-equipped medical educational complexes and hospital facilities become complementary. Hospital administration is becoming more and more important due to a variety of reasons. The expansion of health services and also the advancement of scientific medicine add to the complexity of the problems in hospital administration. Besides its primary and principal functions, namely the care of the sick and injured, the hospital has many other obligations to perform, such as educating and training all those who have to deal with the sick and injured and providing new knowledge both in hospital administration and the clinical field. In order to perform these functions efficiently, the hospital must be organized and administered in a truly scientific manner. Besides various clinical departments, there are ancillary departments, such as clinical laboratory, radiology, dietetics, pharmacy, laundry, house-

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