Creating a comprehensive medical record in a hybrid world

Ms. Melanie Ford, Clinical Industry Consultant ANZ at Lexmark Healthcare, explains why Point of Care Scanning is integral to a more complete medical record.

Hospital Management Asia spoke with Ms. Melanie Ford, Clinical Industry Consultant ANZ at Lexmark Healthcare, and asked her to name the top three issues in healthcare where print media played a key part of the patient journey.

The discussion centred around cybersecurity, managing downtimes, and providing data in formats that is well suited to the digitally disenfranchised. Ultimately though, Ms. Ford said “Whilst these issues are important, the most critical is trying to operate in an emergent clinical situation, making decisions about how to care for your patient where the patient record is missing data.

“Not just data generated in your hospital but from their general practitioner, their pharmacist or the neighbouring hospital that saw them last week. This is where things can go horribly wrong. Omission of data is as dangerous to the patient in your care as inaccurate data. Either way, this rarely ends well.”

In 2012, the Australian Commission on Safety and Quality in Health Care released eight standards whose aim was and is to be the framework for and barometer of safe and efficient practice. The National Safety and Quality Health Service standard communicating for safety aims to supply a nationally consistent level of care. The clinical governance standard, at its core, is there to ensure a comprehensive medical record that is accurate and up to date. By 2013, all hospitals and day procedure facilities began the process of accreditation to all eight standards.

Ms. Ford added: “If we had a single person record that traversed all clinical venues of care and crossed state and national boundaries, these standards would be easier to achieve. Unfortunately, even the Australian My Health Record initiative has been unable to achieve this. Of the 22.65 million records available, a little over half contain data and even that is limited in its scope.

“As clinicians, we base our care on best practice, ongoing education, and access to patient history. If we don’t have access to that information, we either repeat examinations that may have already been undertaken or in an emergency, base our judgement on the information at hand. This is traumatic for the patient, can delay treatment and seriously impact clinical outcomes; not to mention the additional expense. While Electronic Medical Records have obvious advantages, they often don’t have the complete clinical picture. So how do we address that?

“We know that outside of the hospital environment, there are multiple sources of information regarding our health and wellbeing, some digital, some paper, some hybrid and so many more in silos of vital yet inaccessible clinical data. Even within hospitals, the rollout of EMR’s at best can be described as paper-lite rather than paperless.”

Advanced as digital systems are, they do not cover 100 per cent of clinical communications, activities, and actions. One example – that has a long and unfortunate history of errors – is medications, which may be ordered electronically, but administered via a printed and signed paper record in hospitals.

However, this poses a problem, as Ms. Ford mused: “If the patient re-presents after discharge with, for example, the signs and symptoms of hypokalaemia, how can an accurate diagnosis be made if we don’t know which medications were actually administered?”

This is where accurate and automated point of care scanning can fill the gaps.

Ms. Ford elaborated: “Point of Care Scanning isn’t a substitute for batch scanning at discharge. The intent here isn’t to turn clinicians into medical records clerks. Not all records need scanning immediately as some have limited if any clinical importance.

“It’s the documents the patient hands you with their medications, the interstate pathology report that is faxed to you or the discharge summary with a list of clinical conditions that is awaiting filing and scanning. These are of no use to you in the emergency department with an unconscious patient if they become part of the patient record at the end of their encounter.

“Nor are they helpful when the patient re-presents the following day, but their medication reconciliation is in the medical records department awaiting batch scanning. Research suggests that missing clinical data not only adversely affects patients but in close to 60% of cases is likely to delay care.

“The Emergency Care Research Institute (ECRI) even named data integrity (incorrect or missing data in patient records) as one of the Top 10 Health Technology Hazards of 2015. They then went on to name missing clinical information as one of their 2019 Top 10 Patient Safety Concerns.”

A complete digital record has undoubtedly demonstrated benefits to patient care and good clinical decision making.

But therein lies the point of the matter – correct decisions cannot be made with incomplete information, and the assumption that the EMR is the most complete source of information is just that, an assumption.

So how does Point of Care Scanning help?

One simple solution, according to Ms. Ford, lies in a multi-function printer with Point of Care Scanning abilities, which allows for healthcare providers to capture accurate clinical data at the point of care.

“As the majority of a person’s clinical data resides within non-hospital systems (paper, electronic or hybrid), it is important that this information is available to maintain clinical handover from primary to tertiary care in a format that is suitable for its intended audience,” Ms. Ford explained.

“Point of Care Scanning isn’t just for records coming from outside the organisation. Not all hospitals or primary care practices with EMR’s systems are completely digital. Therefore, in areas of public or private hospitals where clinical records are on paper, automated point of care scanning is critical.”

Among some of the other key benefits to point of care scanning – on top of its ability to capture clinical data at the point of care – includes being able to automate the sorting and indexing of information at the multi-function printer, allowing for healthcare providers to use space resources more efficiently, as well as supporting patient care with clinical data in the EMR in a faster and more efficient manner.

Multi-Function devices are also important to maintaining a clinical record in the event of planned or unplanned downtime. Ms. Ford said: “Cyber-attacks can paralyse a hospital for weeks with their effects lasting much longer. Looking after patients is risky where parts of the record are missing. Imagine what happens if it’s all gone?

“The Lexmark Downtime Assistant, interoperates with existing systems, and maintains forms and patient data in the most recent version. It’s secure, doesn’t rely on an operational network, and supports the scanning of information ready for upload when the EMR becomes operational.”

Ms. Ford was keen to highlight that her intent wasn’t to “…negate the obvious benefits of digital records. A complete digital record has demonstrated benefits to patient care and clinical communication. Still, given that the sharing of clinical information is often incomplete, and that semantic interoperability is possibly even further behind, how do we deal with the patient who presents to your Emergency Department with a handful of paper?”

Perhaps the answer is already there in your ED, clinic, GP practice or nurse’s station. You just forgot how interoperable, adaptable, and how very 21st Century your multi-function printer has become.

 

Click here to learn more about how you can avoid communication errors with Lexmark’s Point of Care Scanning solutions. You can also contact Lexmark’s Healthcare Consultant at Jason.tee@lexmark.com for AP or melanie.ford@lexmark.com for ANZ to learn more about Lexmark’s clinical solutions and assessment of your facility’s printing requirements.

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