Records management - Wikipedia
2The Computer-Based Patient Record: Meeting Health Care Needs .. A broader definition of data integrity could also be appropriately applied to patient data. (PQT)-Inspection to the forty-ninth meeting of the WHO . These guidelines do not define all expected controls for assure data reliability and electronic records, secure, computer-generated, time-stamped audit trails at both. Record Definition - In relational databases, a record is a group of related data held added to the CUSTOMER_MASTER table must meet these parameters.
Practical considerations forced the committee to focus on certain high-priority record uses rather than on all possible functions of the record. The four major categories of patient record uses considered by the committee were direct patient care, administration and management, reimbursement, and research.
Translating Customer Needs Into System Requirements Proper system design means achieving a patient record system that properly fits, interacts with, and communicates in the accepted manner of every user community the system supports. This kind of design is necessary if automated patient record systems are to be adopted by users.
The committee defined the needs of patient record users in terms of system function and issues of implementation and operation. System function is what the system enables users to do and what it does for them. Implementation and operation issues relate to the factors users consider in acquiring and installing a system.
These factors are important regardless of the form of the record e. The specific features users seek in patient records and record systems are described below in terms of the computer-based patient record CPR. Most of these desired features are common to two or more major kinds of record users. Unique concerns or needs of a user group are also identified. Box presents an overview of user requirements. Record Content Uniform core data elements In compiling the list of user requirements, the committee noted two special considerations.
First, user needs can conflict with each other—not just among groups e. To the extent possible, the committee resolved such conflicts by using sensible rules of priority. In several cases, however, the conflicts remained nettlesome and are discussed in Chapter 4 as particular challenges to future patient record development.
Second, at a technological frontier, customers may have difficulty expressing or even imagining a need. This situation may well occur with the computer-based patient record, which contains opportunities for functional characteristics that most users would not think to request.
The pioneering designer must not only ask, "What do people want? Patient record systems should offer users at least two additional functions. First, records should be able to guide the process of clinical problem solving. Second, records should support clinicians with decision analysis, reminders, risk assessment, and other "intelligent" features not available with paper records.
Storage The attributes associated with the storage function are record access i. Other features of a patient record system are essentially irrelevant to users if they cannot gain access to the system, to the records in the system, or to the data in the records.
Access can be described in terms of availability, convenience, reliability, 3 and ease of use. A patient record system should allow authorized clinical users convenient access to any record 24 hours a day. This requirement implies an adequate number of conveniently located terminals or work-stations, no system downtime, no lost records or data, and access to the record by more than one user at the same time.
Nonclinical users typically require access to patient record data at least during standard working hours. Different users need different levels and kinds of information see Box The ease with which users locate or retrieve needed data elements depends largely on the record format.
Current paper record formats tend to segregate rather than integrate information; to facilitate communication of needed information, an integrated format is necessary. Thus, records should contain a front-page problem list to allow users to locate desired information.
In addition, record systems should allow users to "flip through" or easily scan records; a table of contents or index would be helpful for this purpose. A patient record database contains many data elements, and each user community has a unique, definable "view" of the database that brings together the elements needed by that community.
Several other capabilities are needed for optimal access. Users should be able to display information at different levels of detail. Moreover, the system should permit virtually every data item to be used as a key for retrieval and should also enable users to access subsets of data. All users, regardless of their level of computer expertise, should be able to enter most queries without the intervention of a programmer; thus, an English-like retrieval language should be part of the system.
Accessing information when needed includes more than finding an available terminal; from the user's point of view, it means an adequate i. Users want to perform their tasks at least as fast as they currently perform them with paper records. Extremely rapid retrieval of information, measured in fractions of a second, is an essential function for primary users of the CPR. In addition, clinicians, who are accustomed to writing or dictating their entries to patient records, want a comparable method in the CPR system to add data to the record.
From the users' perspective, the difficulty involved in learning to use a system also affects access. Thus, operation of patient record systems should require only minimal training. Many physicians are unwilling to devote large blocks of time to learning a new record system, even if ultimately it might make their work easier.
In addition, built-in, displayable "help" documentation on system operation and the data elements should be available to both clinical and nonclinical users.
The question of patient access to records is debated among practitioners. It is likely, however, that the trend toward increasing patient access will continue. Some providers consider it appropriate for patients to enter data e. Recently, functional status and preferences among various treatments have been identified as data that could be recorded by patients to assist practitioners in developing care plans.
Some practitioners encourage patients to audit their records for accuracy and completeness; they may also use the record for patient education. Indeed, as patients become increasingly computer-literate, knowledge-seeking consumers of health care services, the CPR may function as an important patient education tool by offering patients access to resources such as MEDLINE. CPR systems eliminate the need for handwriting and thus improve legibility.
Accuracy of CPRs can be enhanced by data entry screens and logical rules that flag or block inappropriate entries for particular data fields. To the extent that CPRs reduce the need for an intermediary to enter data i. When errors do occur, for legal purposes the original entry and the correction should both be preserved Waller, in this volume.
Data accuracy also has implications for the security and reliability of CPR systems insofar as the systems must ensure that data are not lost or unknowingly corrupted. Without such uniformity, what one patient record user views as complete data may be considered incomplete by another. Data completeness implies that systems will accommodate the currently expected range and complexity of clinical data and that they will permit new data fields to be added and obsolete data fields to be identified.
In addition, it is essential that the health care provider's rationale for clinical decisions be clearly documented. Lack of a recorded rationale hinders the ability of subsequent users of the record to make appropriate judgments regarding patient care, quality assurance, utilization review, reimbursement, and research. For purposes of health services research, patient health status is the single most important data element that is usually missing from the patient records of today.
Formal, interpretable information on health status is a precondition both to case mix or risk factor adjustment and to assessment of the outcomes of care. The research community clearly wants health status information, collected in a standard format, to be a routine part of the record of the future.
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Such records should also document health risk factors e. Technology assessment, clinical investigation, and health services research have been slowed by the lack of reliable, valid, standardized, consistently collected information on the health status and functional level of patients Ellwood, ; Roper et al.
Moreover, practitioners may benefit from routine availability of health status measures. Some evidence suggests that without such measurements in routine clinical practice, physicians and other health care professionals often overlook significant impairments and changes in function among their patients Nelson, In the past two decades, many health services researchers have worked to develop, test, and refine health status measures with sound psychometric characteristics Katz, ; Lohr and Ware, ; McDowell and Newell, ; Lohr, These kinds of methodological advances could greatly increase the practical application of standardized health status data.
The committee acknowledged that the question of whether and how soon health status assessment will influence the quality of care remains to be addressed. To gain a better understanding of the value of health status measures, the committee supported their widespread adoption as a component of the patient record—but under conditions that would permit evaluation of whom they help and of how best they can be employed.
The committee did not identify an optimal set of health status measurement instruments, as this determination was not part of its charge. Rather, to broaden the base of potential comparisons of case mix, care, morbidity, and outcomes, the committee noted the potential value of standardizing or otherwise increasing the compatibility of those instruments now in common use. It remains unclear how outcome data can be gathered and used unobtrusively, inexpensively, and conveniently enough that such activities will become widespread.
Merely adopting a computerized record format may not overcome the barriers that so far have impeded the diffusion of health status measurement into routine clinical practice. Computerization may make the analysis of such information easier but may not affect its collection. The completeness of patient records depends in part on the time it takes to add new information to the record, once that information is available. Data completeness can be enhanced by linkages between CPR systems and ancillary systems e.
Maintaining the quality of patient data also requires that the data have meaning for users. Effective retrieval and use of information from patient records depend on consistency in naming or describing the same findings, clinical problems, procedures, drugs, and other data within a single patient record, across many patient records in a single record system, or in other systems that contain data relevant to the understanding and treatment of patient problems.
Communication among practitioners can be aided by a common clinical data dictionary and a clinical coding system that are interchangeable any clinical data common to different specialists or professions but specific enough to describe the detailed data unique to a profession or specialty.
Health care researchers have a special need for record systems that provide more uniform results than are provided by current systems. Consistent description of clinical content becomes more important with the aggregation of data from many patient records—as in outcomes research, for example.
Standardized data dictionaries, coding schemes, and uniform data sets permit more complete, reliable analyses of care and disease patterns involving multiple sites. First, as discussed in Chapter 1patient and provider privacy must be protected. Second, data and software must be safeguarded against tampering and unintentional destruction.
These requirements demand both system and data security measures. System security refers to the measures taken to keep computer-based information systems safe from unauthorized access and other harm. Data security involves protection of data from accidental or intentional disclosure to unauthorized persons and from unauthorized alteration.
Data security includes both data confidentiality and data integrity. Data confidentiality is a ''requirement whose purpose is to keep sensitive information from being disclosed to unauthorized recipients" National Research Council [NRC], Confidentiality requires appropriate action by physicians, nurses, midwives, secretaries, medical technicians, paramedical staff, social workers, hospital managers, computer staff, and research investigators in health care facilities to safeguard the privacy of patient information.
Confidentiality also requires that computer systems refuse access to unauthorized individuals. In its narrowest sense, data integrity refers to the consistency and accuracy of data stored in computer-based systems. It is a "requirement meant to ensure that information and programs are changed only in a specified and authorized manner" NRC, Data integrity is of paramount importance to the CPR, and care must be taken, especially in distributed CPR systems see Chapter 3to ensure that records can be completely restored in the event of system failures.
A broader definition of data integrity could also be appropriately applied to patient data. Data are said to have integrity if they comply with an a priori stated expectation that they have a defined set of attributes. This a priori set of attributes is unique to the data, to the process operating on the data, and to the data holder. Such attributes might include timeliness e. Data integrity in future patient records might be enhanced by including a data validity field that would flag data that might not be correct.
Data validity would be an additional parameter against which integrity could be judged and thereby controlled. Informing subsequent users that an entry might be incorrect would allow them to discount or ignore the information.
Thus, future CPR systems should permit customization of data entry formats, reporting formats, and display formats—both for and, in some cases, by specific users.
Patient record user needs are simply too many and too varied for any one combination of input, reporting, or display options. Furthermore, research has shown that the ability to customize computer interfaces according to one's preferences and work habits increases user acceptance of computer systems Bikson et al. Conventional formats should be designed and available as default modes, but the users of the patient record of the future should find the record easy to mold to their individual, local needs.
Different formats for displaying information on the screen or on paper should be available. The record should also permit integration across disciplines and professional specialties and provide different "views" 8 of patient data for different users see Box Flexibility is also required to meet the varied reporting needs of users, particularly physician specialties. Doctors need record information available both in easily accessible, standard reporting formats such as letters, insurance forms, school and camp certificates, etc.
Therefore, the CPR system should contain a user-friendly report generator for physicians and others who wish to design specialized reports for their own use. Three different interfaces are important in such interactions: Linkages among the various clinical records pertaining to a single patient are also important to users, who often want a longitudinal patient record—records from different times, providers, and sites of care that are linked to form a lifelong view of a patient's health care experiences.
Linkages are also needed to transfer patient data from one care setting to another e. Linking the records of family members, or the records of individuals who received a certain procedure in a particular facility, may prove useful for some types of epidemiological analysis.
The aggregation of patient data for large-scale analysis, however, requires more complicated kinds of linkages. Integration of relevant subsets of data across institutional boundaries is especially important as researchers attempt to understand diseases and episodes of illness independent of the particular institution or health care professional with whom patients find themselves at a particular phase of their illness.
Patient record systems should also offer linkages to other databases and other sources of information. Connectivity makes several other demands on the system as well.
To make it simple for the practitioner to interact with the record, data entry must be almost as easy as writing, and databases must be organized in such a way that any terminal or microcomputer on the system can retrieve requested data. As noted earlier, communication among practitioners depends on common data dictionaries and clinical coding systems.
To interface easily with a database or registry requires a different sort of connectivity. Workstations must be designed with telecommunications interfaces that allow the user to switch almost instantly between the information in the record and its relevant counterpart in the external knowledge base.
To achieve such efficiencies, computer-based patient record systems must include certain capabilities—in particular, one-time data entry and performance of routine tasks. Further, CPR systems should be designed so that data content is streamlined and unnecessary data are not collected.
Any data entered into the system should be available for a variety of uses, eliminating the need for redundant data entry. The need for manual extraction of data and re-entry procedures greatly diminishes the value of a system. The system should be designed to ensure that data are available to support patient care, organizational operations, and decision making. Thus, data must be viewed as an organizational resource, not property "owned" or controlled by the departments that happen to collect them or that are the primary users of the data.
The CPR system should be a part of an integrated patient care information system. If the system is hospital based, it should communicate with systems in the clinical laboratory, pharmacy, respiratory therapy, other ancillary services, referring physician offices, and other care settings e.
If the system is based in a physician's office, it should communicate with the computer systems of local clinical laboratories, pharmacies, hospitals, and other physicians' offices.How To Record Tapes, Records, Reel to Reel onto Computer Family History
In particular, they should permit raw and aggregated data to be moved to another electronic database for further analysis and storage. For example, a hospital or individual physician should be able to extract selected information electronically from a patient care database to send to other internal or external perhaps national databases.
Health care professionals perform many routine administrative tasks in the course of providing services, and they seek ways to reduce this administrative burden so that they can devote more time to direct patient care, research, and education. Patient record systems should provide the capacity to generate routine documents based on record data automatically, to submit insurance claims electronically, and to report adverse reactions or occurrences of tracked diseases automatically. Computer-based records must be designed to avoid the mere replication of paper record features and behaviors that, upon reflection, have little or no value to users.
Examples of waste include information that is routinely collected but never used; inflexible, redundant formats for recording data that result in duplicative information e. Such features and behaviors add cost rather than quality to the record system. The committee did not specifically investigate the nature or scope of such wasted effort in present-day records, but members shared the general impression that it abounds.
In developing the CPR, time would be well spent in practical research to identify and remove these "non-value-added" steps, features, and data elements, with the intent of producing a record that is leaner, less complex, and more streamlined than that of today.
This process is likely to require changes in regulations or laws, and the committee urges that such changes be analyzed, recommended, and adopted see Chapter 5. Guidance of Clinical Problem Solving It has been suggested that a physician's thought process is formed in part by his or her interaction with the patient record Young, According to Weeda properly formatted patient record can guide clinicians through the process of clinical problem solving.
First, the chance of follow-up for a problem listed in the problem list is significantly greater Simborg et al. In other words, the POMR's front-page problem list is a particularly useful feature. Second, it is easier to relate information in the record to a relevant problem Aranda, Third, the format reflects an orderly process of problem solving, a heuristic that aids in identifying, managing, and resolving patients' problems Weed, The committee unanimously believes that patient records should guide and reflect clinical problem solving and that the mere translation of current record formats, data, and habits from paper to computer-based systems will not alone produce the range of improvements in care potentially achievable in a truly reformed patient record system.
Current systems include behaviors and record forms that produce substantial waste, imprecision, and complexity in a care system less and less able to tolerate that burden.
The committee also believes that the shift from a paper to a computer-based system offers an opportunity to study and improve clinical approaches and methods that are reflected in the record.
Some formats are likely to be more effective than others in guiding and encouraging the use of an efficient, scientific problem solving method in the clinical process.
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The committee did not reach unanimity regarding the choice of a single preferred record format to support improved clinical care. A majority maintained that no clearly superior alternative existed to warrant specific recommendation; this group therefore concluded that, at present, the primary pertinent requirement of a CPR is that it be sufficiently flexible to accommodate a wide range of present and future record formats.
Although it did not specifically recommend use of the POMR, the committee did consider certain components of the POMR to be highly desirable in any computer-based record system. Those components include 1 a structured, systematically collected database; 2 an easily reviewed and updated problem list; and 3 routine recording of clinical formulations and plans for care and follow-up.
The committee urges continuing research to develop, design, and assess improved record formats that, over time, are likely to be used more consistently throughout the health care system. A minority of committee members maintained that one patient record format—the problem-oriented medical record first described by Weed—offers a superior alternative in guiding and supporting scientific reasoning and clear communication in medical practice.
In extreme cases, the item may require both disaster -proofing and public access, such as the original, signed US Constitution. Civil engineers may need to be consulted to determine that the file room can effectively withstand the weight of shelves and file cabinets filled with paper; historically, some military vessels were designed to take into account the weight of their operating procedures on paper as part of their ballast equation [ citation needed ] modern record-keeping technologies have transferred much of that information to electronic storage.
In addition to on-site storage of records, many organizations operate their own off-site records centers or contract with commercial records centres. Retrieval of records In addition to being able to store records, enterprises must also establish the proper capabilities for retrieval of records, in the event they are needed for a purpose such as an audit or litigation, or for the case of destruction.
Record retrieval capabilities become complex when dealing with electronic records, especially when they have not been adequately tagged or classified for discovery.
Circulating records Tracking the record while it is away from the normal storage area is referred to as circulation. Often this is handled by simple written recording procedures. However, many modern records environments use a computerized system involving bar code scannersor radio-frequency identification technology RFID to track movement of the records.
These can also be used for periodic auditing to identify unauthorized movement of the record. Disposal of records Disposal of records does not always mean destruction. It can also include transfer to a historical archive, museumor private individual. Destruction of records ought to be authorized by law, statute, regulation, or operating procedure, and the records should be disposed of with care to avoid inadvertent disclosure of information.
The process needs to be well-documented, starting with a records retention schedule and policies and procedures that have been approved at the highest level. An inventory of the records disposed of should be maintained, including certification that they have been destroyed. Records should never simply be discarded as refuse. Most organizations use processes including pulverization, paper shredding or incineration. Commercially available products can manage records through all processes active, inactive, archival, retention scheduling and disposal.
Some also utilize RFID technology for the tracking of the physical file. Managing digital records[ edit ] The general principles of records management apply to records in any format. Digital records, however, raise specific issues. It is more difficult to ensure that the content, context and structure of records is preserved and protected when the records do not have a physical existence.
This has important implications for the authenticity, reliability, and trustworthiness of records.
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Much research is being conducted on the management of digital records. Based at the School of Library, Archival and Information Studies at the University of British Columbiain Vancouver, British Columbia, Canada, the InterPARES Project is a collaborative project between researchers all across the world committed to developing theories and methodologies to ensure the reliability, accuracy, and authenticity of digital records.
Functional requirements for computer systems to manage digital records have been produced by the US Department of Defense The United Kingdom's National Archives and the European Commission,  whose MoReq Model Requirements for the Management of Electronic Records specification has been translated into at least twelve languages funded by the European Commission. Particular concerns exist about the ability to access and read digital records over time, since the rapid pace of change in technology can make the software used to create the records obsolete, leaving the records unreadable.
A considerable amount of research is being undertaken to address this, under the heading of digital preservation. A digital archive has been established by PROV to enable the general public to access permanent records. Archives New Zealand is also setting up a digital archive. There is substantial confusion about what constitutes acceptable digital records for the IRSas the concept is relatively new. The subject is discussed in Publication and Bulletinbut not in specific detail.
Businesses and individuals wishing to convert their paper records into scanned copies may be at risk if they do so. Current issues[ edit ] Compliance and legal issues While public administration, healthcare and the legal profession have a long history of records management, the corporate sector has generally shown less interest. Corporate records compliance issues including retention period requirements and the need to disclose information as a result of litigation have come to be seen as important.
Statutes such as the US Sarbanes-Oxley Act have resulted in greater standardization of records management practices. Since the s the shift towards electronic records has seen a need for close working relations between records managers and IT managers, particularly including the legal aspects, focused on compliance and risk management.
Security Privacydata protection, and identity theft have become issues of increasing interest. The role of the records manager in the protection of an organization's records has grown as a result. The need to ensure personal information is not retained unnecessarily has brought greater focus to retention schedules and records disposal. Transparency The increased importance of transparency and accountability in public administration, marked by the widespread adoption of Freedom of Information laws, has led to a focus on the need to manage records so that they can be easily accessed by the public.
For instance, in the United Kingdom, Section 46 of the Freedom of Information Act required the government to publish a Code of Practice on Records Management for public authorities. Adoption and implementation Implementing required changes to organisational culture is a major challenge, since records management is often seen as an unnecessary or low priority administrative task that can be performed at the lowest levels within an organization.
Reputational damage caused by poor records management has demonstrated that records management is the responsibility of all individuals within an organization. An issue that has been very controversial among records managers has been the uncritical adoption of Electronic document and records management systems.
Impact of internet and social media Another issue of great interest to records managers is the impact of the internet and related social media, such as wikisblogsforumsand companies such as Facebook and Twitteron traditional records management practices, principles, and concepts, since many of these tools allow rapid creation and dissemination of records and, often, even in anonymous form. Records life cycle management A difficult challenge for many enterprises is tied to the tracking of records through their entire information life cycle so that it's clear, at all times, where a record exists or if it still exists at all.
The tracking of records through their life cycles allows records management staff to understand when and how to apply records related rules, such as rules for legal hold or destruction. Conversion of paper records to electronic form As the world becomes more digital in nature, an ever-growing issue for the records management community is the conversion of existing or incoming paper records to electronic form.
Such conversions are most often performed with the intent of saving storage costs, storage space, and in hopes of reducing records retrieval time. Tools such as document scannersoptical character recognition software, and electronic document management systems are used to facilitate such conversions. Education and certification[ edit ] Many colleges and universities offer degree programs in library and information sciences which cover records management.
Schools in Canada also provide specialized education opportunities in records management. The Faculty of Information at the University of Toronto allows students in the Master of Information program to concentrate their studies in Archives and Records Management.
Electronic records management systems[ edit ] An Electronic Document and Records Management System is a computer program or set of programs used to track and store records. The term is distinguished from imaging and document management systems that specialize in paper capture and document management respectively. Electronic records management Systems commonly provide specialized security and auditing functionality tailored to the needs of records managers.
Department of Defense standard While these requirements were initially formulated in collaboration with central government, they have been taken up with enthusiasm by many parts of the wider public sector in the UK and in other parts of the world. The testing program has now closed; The National Archives is no longer accepting applications for testing. The National Archives requirements remain current.
In some cases, they also offer storage for records maintained in electronic formats. Commercial records centers provide high density storage for paper records and some offer climate controlled storage for sensitive non-paper and critical vital paper media. There is a trade organization for commercial records centers for example, PRISM Internationalhowever, not all service providers are members.