Fase III: Ejecución de la Auditoría

Some medical records are still paper-based and EHR systems are currently machine-readable versions of paper-based records (Carter, 2001). It is important to know what is meant by a patient record, “The patient record is an account of a patient’s health and disease after he or she has sought medical help. The record should usually contain findings, considerations, test results and treatment information related to the disease process.” (van Bemmel & Musen, 1997). The birth of the first known record backdates to the Fifth Century BC with Hippocrates as the

16 pioneering father. Hippocrates recommended that a medical record should have two main goals that of:

 accurately reflecting the course of disease, and

 Indicating the probable cause of disease.

These goals are still used in the present day medical records but electronic health record systems can provide more functions such as interactive alerts to clinicians, interactive flow sheets, and tailored order sets of which paper-based records cannot do

(van Bemmel & Musen, 1997). The medical record in (Figure 2.2) shows an example of one of Hippocrates’ patient records.

Figure 2.2. Example of Hippocrates’ patient record. Adapted from (van Bemmel & Musen, 1997)

The first patient-centred record was adopted at Mayo Clinic in Rochester, Minnesota in 1907. The notes for each patient were kept in a single file and in no particular order. In 1920, the Mayo Clinic management improved on the previous innovation and agreed upon a minimal set of data that all physicians were compelled to follow. This set of data has become more or less

':Apollonius was ailing for a long time without being confined to bed. He had a swollen abdomen, and a continual pain in the region of the liver had been present for a long time; moreover, he became during this period jaundiced and flatulent: his complexion was whitish"

After dining one day and drinking to excess, Apollonius "at .first grew rather Hot and took to his bed. Having drunk copiously of milk; boiled and raw, both goat's and sheep's, and adopting a thoroughly bad regimen, he suffered much there from."

There were exacerbations of the fever; the bowels passed practically nothing of the food taken, the urine was thin and scanty. No sleep. Grievous distention, much thirst, delirious mutterings. . .... About the fourteenth day from his taking to bed, after a rigor, he grew hot; wildly delirious, shouting, distress, much rambling, followed by calm; the coma come on at this time . ... About the twenty-fourth day comfortable; in other respects the same, but he had lucid intervals ... About the thirtieth day acute fever; copious thin stools; wandering cold extremities, speechlessness. Thirtieth day: Death

17 the framework of today’s medical record. Despite the initiative towards standardization of the patients’ notes, the notes were still not kept in a satisfactory order. That has led (Weed, 1968) to improve the organisation of patients’ notes by introducing a problem- or task-oriented medical record. (van Bemmel and Musen, 1997). This was the birth of the patient-centred medical record that has now evolved from the Hippocrates type of unstructured chronological events to today’s problem-oriented structured events (Cunningham, 2003).

Paper-based records have some disadvantages that were mainly derived from the medical advancements. Progress in medical knowledge has led to an increasing number of

specialisation areas. This has seen a 21st century that has a more mobile and a health conscious

patient population that has resulted in a state where patients’ medical records are now accumulated in a variety of locations, ranging from their GP to their physiotherapist

(Schoenberg & Safran, 2000). It should be noted that each health care provider keeps their own medical records for each of their patients. There is no integration of data from various

providers treating the patents. These numerous entry points have resulted in a fragmented “island of information” (Cunningham, 2003). Paper records can only be at one place at a time and sometimes cannot be found at all when clinicians want to use them. Handwriting may be illegible and data may be incomplete and notes may be too ambiguous and hard to interpret. Paper–based records cannot give the care providers automatic reminders, warnings or advice. Retrospective research on paper-based research can be laborious as much data may be missing or useless (Coiera, 2003).

Despite some disadvantages, paper medical records have many things that are regarded as advantages. The paper-based record possesses some remarkable attributes as a physical and informational system. It is portable and easily accessible but nowadays computers are small and portable as well (Coiera, 2003). Notes can be worked on in most places unlike a computer

18 that requires power to connect to a computer network (Coiera, 2003). Paper and pen are

familiar methods of recording information; therefore no special training for medical staff is required. Computer use may require on workplace training for the existing healthcare professionals

(Coiera, 2003). Access to data written on paper can give a very direct feeling; whereas, browsing through quantities of notes permits scanning of what is recorded

(Coiera, 2003; van Bemmel & Musen, 1997).

The following (Table 2.3) summarises the advantages and disadvantages that are related to paper medical records. These disadvantages outnumber advantages and may have a potential negative impact on the health and wellness of a patient. The need to overcome these

19 Table 2.3 Advantages and Disadvantages of Paper-Based Medical Records (adapted from Cunningham, 2003).

Advantages of Paper-Based Patient Records Disadvantages of Paper-Based Patient Records

Portable Record can only be at one place

at a time

Access is self-contained Records not always available Paper & Pen are always a familiar method

of information – no special training is required

Record can be ambiguous, illegible or even incomplete

Access to data can feel very direct Storage of paper consume large amounts of physical space

Records require little structuring Data relating to one individual may be in varying locations, leading to logistical problems

Paper is relative informal medium, as it imposes few models on the data that is captured

Paper record cannot actively draw attention to anomalies in patient’s data

Paper is fragile, susceptible to damage, and may degrade over time

Structuring of paper records may be personal, ma become difficult to interpret by someone else

Absence of formal structure gives rise to increased risk of errors