A patient chart is the basic communication document in medical practice. It provides detailed information about the medical conditions of the patient to both existing and new consultants. If the patient moves to a new location, a doctor at this location can call for the patient record and get an up-to-date representation of the person’s medical condition.
Traditionally, patient charts were kept on paper, with all the problems associated with a paper-based system. Retrieval of a particular chart was a cumbersome procedure and loss of patient charts was a common occurrence in a large setup. The frequent handling of the document also tended to spoil the record, already suffering from illegible writing.
Illegible prescriptions could lead to wrong dispensing of medicines, or at least time-wasting calls to the doctor from the pharmacy. (The emerging practice of e-prescriptions not only eliminates the legibility problem but also enables doctors to consult drug databases for different purposes before finalizing the prescription.)
Confidentiality of patient health information was also not foolproof. There were many places during movement of the record from the record room to the doctor and back to steal the information, if somebody was bent upon it. And lost charts were a potential source for loss of confidentiality.
For all these reasons, paper-based maintenance of patient records are being abandoned by enlightened health establishments.
The Medical Document Imaging Scenario
When medical document imaging is introduced into an establishment, it can be up and running in very little time. The systems are typically easy to use and staff can be trained up quickly.
The system would then capture all patient charts and lab reports into digital format, making them available instantly to doctors in the same or distant premises. Unlike paper documents, reviewing the patient history on the computer screen or PDA is likely to prove a much better experience for doctors.
Because lab reports are scanned and saved to the system at the lab itself, the results become available to doctors much earlier than in a paper-based system.
Paper records can be shredded once they’ve been saved (and even archived) in a digital format. That means savings on storage equipment and space, as well as record-room staff salaries.
Confidentiality is improved greatly because all records are stored in a secure server, accessible only to authorized persons. Systematic backup of the original media to removable media and storing the latter in a secure place can prevent loss of patient information. In case the originals are lost from a system crash or other disaster, the backups can be used to reconstruct it.
Medical document imaging systems can transform medical practice by making patient record retrieval extremely fast, by preventing loss of patient information, by improving security and confidentiality of the information, and by making it easy to transmit the information even to a distant city.
Doctors can access patient charts from their PDAs or workstations, instead of calling for paper records and waiting for it to come. Lab results can be scanned and sent to the repository immediately at the lab, making it available to doctors far more quickly.