Medical records management is a series of procedures for handling patients’ data, and this information needs to be appropriately stored, cataloged, retrieved, and updated when a patient’s healthcare scenario changes. Medical records management systems are often complex, with multiple layers of rules, regulations, and procedures.
That is with good reason as errors in inpatient data could lead to misdiagnosis, incorrect medication, inadequate treatment, insufficient testing, and so forth. In light of this, medical records management companies must implement comprehensive steps in healthcare software product development.
What Does Successful Medical Records Management Entail?
Frequent regulation changes might make it look like managing medical record systems is a taxing job. But following a few steps will ensure a smooth, efficient electronic health records management workflow –
1. Procedure and Protocols
The first step towards efficient medical records management in hospitals is to define a clear set of procedures and protocols. Furthermore, these rules must be updated promptly to reflect organizational changes, growth, expansion, or reduction in department size. Since health records management directly impacts the efficiency of electronic data interchange, the protocols involved must encompass every department and relevant workflows across the hospital.
2. Employee Training
This is one of the most critical aspects of medical records management. The value of a well-trained staff cannot be exaggerated. They must follow the established guidelines when handling patient data to avoid mishandling the information, which may affect medical decisions.
Moreover, patient data has become a coveted target for hackers. While some data loss is due to well-planned and meticulously orchestrated cyber-attacks, most others are because of carelessness. HIPAA regulations stipulate that organizations must train all employees who handle data.
3. Data Security
As mentioned, hackers have improved and are better at breaching digital systems. In light of the growing threat to sensitive patient data, HIPAA compliance has become indispensable for medical records management services. It entails maintaining a minimum standard of data security while handling patient information. That’s because the quality of care and decisions for treatment depends upon patient data integrity. If compromised, it can directly affect patient health. To sum it up, adequate data security is an integral part of good health care management.
Handling medical data is a complex task, and keeping it up-to-date as per new tests, diagnoses, or treatments is extremely important as it can affect future clinical decisions. Manual workflows in medical electronic records management are bound to have mistakes, which lead to lengthy rework and even loss of revenue for providers. So, it makes sense to automate most of the repetitive activities in records management systems. It eventually results in superior medical informatics and a smoother custom healthcare software solutions development process.
Essential Features of an EMR
Whatever approach is taken to create a medical records management system, there are a few features that providers can’t do without –
1. Integration with Third-Party Application
Medical applications bring efficiency to the entire workflow of healthcare. But they’re of little use if they can’t integrate with other platforms and work seamlessly. Practice management solutions that can integrate with an EMR, advanced telehealth solutions, and patient engagement systems enable providers to see patients remotely, pull up their medical records, prescribe medication, and manage non-clinical aspects of their practice. A platform for medical records management must be able to integrate with every mainstream third-party medical application. Broad, comprehensive, integrated healthcare solutions help hospitals deliver better care.
2. Patient Portal
This is where all the patient information is stored, which is accessible to doctors, the medical staff, and the patients. It includes test results, vitals, blood work, clinical history, etc. Providers can update this information after clinical visits so that people can stay informed about their healthcare journey.
Analyzing clinical workflows is known to help improve the productivity of medical operations and non-medical administrative activities. In addition to this, health data analytics helps assess patient information and reveal people at higher risk of chronic diseases. Such an insight would empower providers to take a proactive approach to care instead of the usual reactive one.
Advances in Healthcare cloud computing have enabled cloud-based analytics solutions to work with medical records management software. This, coupled with remote health monitoring systems, allows real-time assessment of patient health. So, electronic health records need to be able to run analytics to help improve patient experiences.
4. Controlling Access
An essential part of privacy measures in medical records management involves restricting access. Stringent regulation about patient data security insists on controlling who can access what. For example, a radiologist cannot have the same access to medical records as the prescribing physician. Access controls prevent unauthorized access to medical records, making it a must-have for medical records management systems.
Parameters To Be Included In Medical Records Systems
Medical electronic records management requires specific parameters so that medical staff may implement appropriate workflows.
1. Patient Demographic
This involves the registration form to collect the following data –
- Address and contact information
- Age and Sex
- Occupation and Company name, company address, and contact numbers
- Emergency contact information
2. Medical History
This must include –
- Current problem
- History of disease
- Past Treatments
- Involvement in physical activities like sports or police, firefighting, or military service
- History of smoking, alcohol, or drug use
- Family history
3. Insurance Information
- Insurance Payer name and contact information
- Policy number
If a Dependent then –
- Responsible Person Name, address, and contact information
- Responsible Person Occupation, Company name, and contact information
- Relationship to the Responsible person
4. Consent Form
This is for cases where there is a specific treatment needed and standard medical protocols. In such cases, providers need a filled consent form that must contain the following information about the treatment –
- Treatment/Procedure name
- Recovery time
- Risks and Benefits
- Consequences in case of no treatment
- Doctor opinions
- Medication and dosage
- Medical equipment or devices
6. Test Results
- Results of blood tests, scans, and imaging
- Interpretation of results
7. Privacy Notice
This is to inform patients about their rights to confidentiality regarding their health information. This is mandated by regulation.
Building an EMR
As we have a good picture of why patient information management systems are essential and how they assist healthcare, we can move on to the steps of building one.
As with any software development, it all starts with an idea. The idea for a patient records system usually comes from what the provider needs, the organization’s size, services offered, and so forth. Moreover, a developer also needs to know about the workflow at the client-side.
Since automated healthcare solutions for healthcare records management must digitize activities, it’s essential to understand the client’s working styles. Otherwise, the developed solution might hinder provider operations rather than help them.
Once the requirements are finalized, the development team must formulate the functionalities and architecture of the medical records system. Subsequently, the team can go about choosing the development process, the technologies needed and build a working prototype. This enables the vendor to estimate the cost and time required to finish the product.
The next step is to build the patient records system as per the process flow and the earlier architecture. It is recommended that the development be carried out module-wise in sequential order, and doing so helps in testing and trouble-shooting each segment as it is finished. This is recommended over simultaneously developing the components in parallel, as errors in any one module might halt the development process.
This is where bugs are identified and fixed. Testing each module individually is followed by testing the patient records software as a whole. Problems revealed in the former help in understanding the functionality of every component. On the other hand, bugs identified in the latter highlight problems with integrating the components to work as one. This step aims to find out if the medical records management system works as per client requirements. Testing and debugging continue until all errors are fixed and the client delivers the solution.
Electronic medical records management software has a place in the future of health tech. As most industries move towards automation, EMR too must evolve to meet the challenges that lay ahead. Patient record systems management has been a game-changer in healthcare. As a developer, it is essential to know that your software will impact people’s health, both directly and indirectly, by affecting hospital workflows. So, be sure to be comprehensive and meticulous in your approach.
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Written by Riken Shah linkedin
Riken's work motto is to help healthcare providers use technological advancements to make healthcare easily accessible to all stakeholders, from providers to patients. Under his leadership and guidance, OSP Labs has successfully developed over 600 customized software solutions for 200+ healthcare clients across continents.