Looking for the System of Record

What is your “System of Record”? Which database do you use when you need the absolute current, most accurate and complete patient record file?

If you are like most medical professionals, your medical software and related databases are growing in number and complexity. The databases are becoming dramatically larger in size. You have probably changed software at least once in the last decade.

This article will discuss the dynamic need to identify and maintain a database which contains the complete set of authentic records for each patient. Among other titles this database is often referred to as the System of Record or Master Record.

Create your Master Record

Declare a Database where ALL patient information is validated and recorded. You will have several databases. Notwithstanding, ALL patient information is recorded (or referenced*) in the Master Record file.

· Establish business rules for the validation and use of all patient information

· Define functional use business rules for the Master Record file

· Questions about authenticity of data are referred to this System of Record (SOR)

· Validate new data that is introduced into any of your various systems, against the System of Record,

· The new data is either rejected in favor of the System of Record, or

· By predetermined business rules, the new data is accepted and replaces the old data in the System of Record,

· Business rules should stipulate which, if any, other data base(s) should be updated in concert with the new information.

*Some information will be stored in other databases, such as images, notes and lab results. A data item in the System of Record points to that “out-of-system” information. This linked reference is validated information by reference.

The System of Record:

· is not an extract,

· is not a “view”,

· is not an image of selected information.

It is essential that the assigned database, the business rules governing it use and functions, and its data files be:

· Identified

· Documented

· readily available upon demand.

When any new system is put into place:

New system implementations must comply with the defined business rules. For example, before installing a Patient Portal system the following questions need to be answered. Use or modify related business rules as needed.

· will new or changed patient information be accepted in the new system?

· will the new or changed information override the “System of Record”?

· will any other system need the new or changed information?

· what is an acceptable delay in updating other systems with the new information? (real time, over night, on request)

· what checks and balances are required to insure data accuracy across all systems?

Why do you need a Designated Record?

1. Insure accuracy of information across the spectrum of your practice

2. Insure timely access to patient data by Practitioners and office staff

3. Minimize redundant data entry

4. Provide a known path to all patient data

5. Provide a method for entering and validating new information

6. Allow for compliance with an audit by any governing body

7. Allow for compliance with legal requests for patient information

8. Provide a “one touch” source to fulfill a patient request for medical records

9. Support Meaningful Use.

Real life example:

Recently I received data files for a conversion. The data files were not current or complete. I requested and received another set of files which were also not the correct files. I needed the “System of Record” files. I obtained permission for remote access to the server, identified and obtained the database where current and complete records were maintained. Had they been clearly identified and known to key employees, several days of delay and unnecessary work would have been avoided.

Now is a good time:

Don’t wait until you have a crisis. Now is an excellent time to locate your System of Record files. Label them clearly. Provide documentation and training for your staff. If you don’t have a System of Record data base, now would be a great time to create it.

Summary:

Patient care today is better and more complex than ever. Providing quality and managing complexity come at a cost. The cost is mostly putting in place and maintaining solid internal controls. The System of Record is an essential control. Medical professionals need the assurance of accurate and available information.