Paper Health Record is a chronological written account of a patient’s examination & treatment in a physical format that includes the patient’s medical history & complaints, the physician’s physical findings, the results of diagnostic test and procedure and medication and therapeutic procedure.
Problems with the paper-based system run the gamut. Some are just inconvenient: waiting for vaccination records before a parent can take a child to camp or enroll the child in school, or making a trip across town to take the child’s records to another doctor. Others are critical: for example, treating a patient with a chronic condition or who is in a life-threatening situation far from home, but unable to supply the healthcare provider with detailed medical information.
The problems affect both healthcare providers and patients. For instance, doctors must be sure that access to paper records is limited to authorized personnel and must keep track of physical files that can be inconvenient to move around. Patients suffer because there are health benefits available that a paper-based system cannot support: post-visit interaction with a doctor by electronic communication; the ability to track one’s own health information and more closely follow detailed treatment plans; and, of course, the ability to provide a physician with instant access to critical information, especially in an emergency.
The inconvenience of paper-based systems
Dificulties in sharing history and lab results with other doctors When doctors do consultations, accept new patients, or review lab results, paper-based information is almost always involved. That means information is transmitted via fax machine, telephone conversation, courier, or mail. All these methods have the potential for misread or misheard data, lost information, delay, and breaches of security.
Inconvenience of securing vaccination records for camp and school enrollment Almost every childhood activity outside the home requires proof of vaccination. That means a trip to the doctor’s office for the patient or the parent. A paper-based system costs your family time.
Recounting medical history for every new doctor Nearly every new healthcare provider a patient sees will need to review his or her medical history. People move and travel more than ever, so this need is especially acute. No one can be expected to remember his or her entire medical history, and the record will be remembered even less accurately when a patient must see a new doctor in an emergency.
No support in caring for aging parents far away Many adults find themselves taking care of their aging parents, and they often have to do so from far away. Medical information is almost always written down or conveyed in conversation, leaving long-distance caregivers with an additional burden. They have no convenient way to keep track of prescriptions, interact with a physician, review test results, or be sure that the parent is following the doctor’s treatment plan.
No easy way of getting quick answers to follow-up questions Doctors want to help patients as much as they can, especially with matters such as following the treatment plan, providing more details about a condition, or finding general information about lifestyle choices. But the lack of connectivity means that patients have to wait by the phone or play “telephone tag” with their healthcare providers instead of using e-mail or accessing on-line articles that physicians and others have made available.
Lack of confidentiality in a paper-based system
Patients do not want their sensitive, personal medical information stored in a way others can easily access Doctors are committed to honoring the trust patients place in them, and they are bound by laws, regulations, and rules of ethics to protect confidentiality. But under today’s paper-based system, privacy is most often a matter of lock and key: paper records are kept in file cabinets on the premises of a healthcare provider, and older records may be stored off-site. When records are being accessed—when doctors and nurses are referring to them during an office visit, for instance—privacy is often a matter of trust: notes regarding patients are kept in file folders that rest in plastic trays attached to an exam-room door, or on a billing clerk’s desk, or in a pile awaiting lab results.
No way to keep track of who sees paper records or to keep unauthorized people out Unlike electronic records, paper records can be examined without any record of who looked at them, when a person looked at them—or copied them—and why. While security is always a priority for administrative staff and medical librarians, a record casually left out for even a few moments can easily be examined or even copied by unauthorized persons.
Patients, especially those with serious illnesses or those who have confided compromising secrets to their doctors, understand that if their information is exposed, they could be irreparably harmed. They fear the loss of a job, embarrassment at home or work, bias, and the inability to get insurance coverage.
Lack of access in the paper-based world
No instant, constant access to your healthcare information Paper records have to be carried from place to place, faxed, or summarized in a phone call. The only way this transferred information is preserved is if it has successfully been received and placed in your medical file.
No guarantee for information backup Your paper-based records could be destroyed by fire, flood, or other catastrophe, or they could be damaged or stolen. Unless the doctor has made copies of every paper in the filing cabinet, that part of your medical history is lost.
Illegible handwriting in records and prescriptions Paper records are a mix of typed text and handwriting, and prescriptions are usually written completely by hand. Illegible handwriting in healthcare information can mean the loss of potentially important data when someone returns later to find that he or she cannot read the information written. In addition, pharmacists may make mistakes filling prescriptions because of illegible handwriting, or may have to spend extra time calling the doctor’s office to get clarification about a prescription.
Patients with chronic conditions cannot easily get the information they need Short of conducting their own research in a medical library, patients have no way of learning how to take better care of themselves or better understand their condition in light of details from their medical test results and treatment.
Recalls are slowed or may be incomplete When medical devices and drugs are recalled, either by the Food and Drug Administration or by the companies that manufacture them, there is no system in place to quickly and efficiently contact physicians and their patients to advise them what to do.
Paper Health Record is one of the most inconvenient mode of storing the medical information for the patients & the healthcare providers causing them problems like errors in treatment, delay in understanding the complication and difficulty in storing & using the records for further references.
Author: Sneh Gupta
Date: 22 December 2015
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