Paper-based vs. digital medical records

Jean Marie Harelimana’s 76 years on earth could as well be defined in one adjective: spic-and-span. This neatness is not just in the manner the Gisagara resident holds his outward appearance, but also in how he documents his life. The Ndora Sector resident has his pride in archiving every bit of paperwork that passes through his life. Harelimana never discards his bank transactions documents, including those of ATMs—that even fade within a short time. But it is in his medical records that the habit of keeping paperwork is can best be understood. He has kept them for years, some dating back to 1991. “It has been just an innocent habit, and, until recently, it didn’t even cross my mind that these medical records could be of any use,” Harelimana said. “But looking at them all nowadays, I see that I can tell what I have suffered from over the years basing on the diagnosis and the medicines that worked for me.” But Harelimana’s paperwork is of the past. The digital era is fast taking paperwork by the throat and crushing them away. Today, much of the record is kept in digital format. The world is in the electronic medical record (EMR) era. EMR is a digital version of the traditional paper-based medical record for an individual. The EMR represents a medical record within a single facility, such as a doctor’s office or a clinic. There are a number of different types of digitised health records that contain most of the same types of information. A personal health record, for example, is health-related documentation maintained by the individual to which it pertains. An electronic health record is an official health record for an individual that is shared among multiple facilities and agencies. Keeping such records at personal level not only facilitates healthcare processes but is also crucial when legal issues come up. When a claim is made, the first and most important witness to be called on is the medical record. Armed with the record, a patient can sue for negligence or whatever else a hospital or doctor did not do right. The story would be different if one was compelled to chase for the records from some healthcare facility that would be reluctant to release them. Crucial past of paperwork The old paperwork system that is fast giving way to digital records, though with its shortcomings, was much more reliable to the patient despite the many disadvantages to the hospital or doctors. Patients were required to buy notebooks at hospital facilities. These notebooks were used for medical records, with diagnosis and treatment noted therein. A patient was required to not only keep the notebook safe but also carry them to the hospital for subsequent visits. In some hospitals, the notebook was not used. Instead, a single sheet of paper was all a doctor scribbled the often illegible words on. This diagnostic note was then taken to other units during the treatment but the patient was required to keep and bring them. It was a delicate affair of managing one’s health record. Dr Emile Rwamasirabo, a urologist at King Faisal Hospital, Rwanda, says paperwork recordings copy used to take a long time to deal with because one nurse or doctor could spend hours treating one patient along with searching for the patient’s file. He said patients could lose data notebook. Besides, for healthcare providers, deciphering the notes was considered a nuisance that sometimes required the assistance of colleagues and, if a signature is present and legible, a call to the doctor who diagnosed the patient. Often, no name is left on the form. From the patient’s perspective, illegible handwriting can delay treatment and lead to unnecessary tests and inappropriate doses which, in turn, can result in discomfort and death. For instance, according to the Journal of Royal Society of Medicine, in 1999, an American cardiologist caused the death of a 42-year-old patient when his prescription of 20mg Isordil, an antianginal drug, was misread by the pharmacist as 20mg Plendil, an antihypertensive drug. “Poor handwriting undoubtedly contributes to another inconvenient truth: the high incidence of medical errors,” the journal says. The problem or paperwork and illegible scribbles, the journals adds, is that sloppy handwriting can be interpreted by a court as ‘sloppy care’ if it came to legal settlement. In the Medical Defence Union’s Ten Commandments of record keeping, ‘Thou shalt write legibly’ comes top of the list. Tablets and mouse clicks The culture of EMRs is sweeping like wild fires. It is no longer such a fancy thing to find a doctor armed with a tablet with which they jot down diagnosis and ask an attendant to direct the patient to next attendee within the hospital. Some hospitals use computers in which a doctor enters records. Others incorporate the use of both soft and hard copies, where a patient’s records are kept in file as well as on computers. For instance, at International Air Ambulance, a healthcare provider in East Africa with major presence in Kenya and Uganda, not a single sheet of paper is involved. A patient provides a medical card at the reception where it is scanned and the patient registered into queue via a computer portal. The network is such that every doctor on duty will have the patient’s name at their machines and call them for examination accordingly. The doctor then enters examination notes on computer and dispatches it to all units so that if one has to proceed to the lab for some urine or stool specimen, the lab will have received the doctor’s notes via computer. Dr Rwamasirabo, of King Faisal Hospital, says: “It takes a few minutes for a patient to register and instantly find medical records. It is easily accessible to other doctors; they treat you directly seeing your previous computerised records.” This is probable the near-future of all medical facilities across the world. In Rwanda, the Ministry of Health says all medical facilities will be compelled to switch to digital format after the necessary infrastructure is laid because technology is in the driving seat of the global development vehicle. There are 18 dispensaries in the country, with 16 prison dispensaries, 34 health posts, more than 430 health centres, 39 district hospitals and four national referral hospitals. With a sound EMR system, this means if a patient used the Central University Teaching Hospital at one point, the next time they go to King Faisal Hospital, their records would be found on the data base. This cuts the doctor’s dilemma on checking medical records based on the usual interview of “have you ever suffered from blood pressure?” and such. Doctors say this stage in the development is for a patient’s good, protecting them and saving time because it is fast and reliable. In the EMR system, patients, too, have access to medical data, though practically, a doctor is expected to explain to the patients the treatment options and diagnosis. Weighing the pros and cons Aphrodise Niyonteze, a resident of Masaka Sector in Kicukiro District, says digital practice is fast and reliable. However, some patients have misgivings about the whole idea of hospitals keeping medical records. Some say it is selfish in that a patient would be expected to return to the same facility if they are to base their treatment on the medical history. Mediatrice Kanyange, from Kimironko, Gasabo District, says in the past, patients kept their own records and enjoyed the luxury of using them at different facilities they visited. “How could one trust computers? A malfunction of any kind could see lots of data lost unless there are safely backed up. Besides, with paperwork, one can easily walk into a pharmacy late in the night and show the pharmacist what medicine they really need,” Kanyange says. “Some of those medicines they prescribe have ‘technical’ names that one cannot remember after a few weeks unless they keep the labels with them. That’s where the paperwork is surpasses the computers.” On going to a different facility and yet in need of medical records, Dr Rwamasirabo says one can always request for their medical records, which can be printed in a summary form but in that case if institution needs more detail, they send all re-file data. However, he adds that whether you print a medical data for a patient or not is the most important thing; what is of essence is to educate patients. “Normally, each doctor has to explain to patient all about their heath because sometimes they do not understand what we write on their paper,” he says. Dr Julieta Lucas, a general dentistry and orthodontics in Kigali, says the most important thing is to interact with patients in a good way. “What patients need is education about their health, not only giving them data but also let them learn about their body and what is affecting them,” he says. What you can do If you want to minimise the risk of error, you need to create a summary of your own medical records and bring them to every doctor’s visit or hospital admission. At minimum, keep a personal record of: Your family medical history. You may be predisposed to many medical problems. Inheritable conditions can range from cardiovascular disease to cancer, from depression to other forms of mental illness. Detailed knowledge of your genetic susceptibility is important to the doctor caring for you. Your personal medical history. Do you suffer from diabetes? Do you smoke cigarettes? Have allergies to certain medications? Physicians need this information so they can hone in on the cause of a specific symptom or avoid post-operative complications. Your medications. Different drugs can interact with one another in negative and potentially deadly ways. Providing a list of your medications (including the dosage) at the start of each medical visit can reduce the chance of a problematic drug interaction.