A growing population has contributed to South Africa’s hospitals and healthcare practitioners dealing with increasing numbers of patients every day. The high volumes of medical records all containing highly confidential information present a multitude of risks for both the institution and its patients if not properly managed.
This is according to Anthony Eedes, GM at Metrofile, who says the majority of local healthcare providers utilise paper-based records, which poses a host of challenges that not only affect the primary function of patient care, but also their ability to manage their business efficiently.
“When a patient is in a critical condition and requires immediate medical treatment instantaneous retrieval of vital medical records can mean the difference between life and death,” says Eedes.
He says that medical record mismanagement can result in delays in delivering necessary medical treatment, as well as incorrect diagnosis. “Ineffective medical records management ultimately shows poor practice and an inability to provide consistent and reasonable healthcare, instigating reputational, financial and legal consequences, amongst others, for the medical institution.”
Eedes adds that untraceable patient information due to medical records mismanagement also makes it difficult to defend clinical negligence, disciplinary inquiries, malpractice cases and debtor obligations. “Other than the legal consequences there are real compromises in terms of responsible service delivery, which by law doctors and medical institutions are mandated to provide.”
He explains that medical institutions currently have a choice between Electronic Records Management (ERM), traditional paper-based records management or a system that is a hybrid of both solutions. “International trends reveal a move towards ERM which is arguably more secure, reliable and readily available but does require an initial financial outlay and a sophisticated systems infrastructure.”
Eedes says that, from an efficiency perspective, paper-based medical records are problematic due to issues such as storage space, provision of access controlled facilities, the requirement of excessive human resources to manually manage the system, multiple filing areas resulting in little or no track and trace capabilities, and duplications of files due to files being misplaced or simply lost. “Additionally, moisture, fire and insects pose a real hazard in terms of health and safety, as well as exposing irreplaceable documents to potential damage.”
The best way to combat the challenges of paper-based medical records systems, he says, is to educate staff on the preparation and completion of records, as well as creating an understanding of the process of patient records from creation to destruction. “However employing a dedicated records manager or outsourcing records management to a reputable service provider would be the best solution.
“Medical professionals and institutions need to constantly review their existing records management systems and develop systems that best mitigate legal and financial repercussions, while increasing operational efficiencies to ultimately serve their patients more effectively,” says Eedes.