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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.

The Anatomy of a Medical Archive

The Medical Archive is comprised of five parts:

1. Structural Process

2. Composition of storage files

3. Investigative Search

4. Delivery

5. Archive Analysis (analytical search)

Understanding these components and their interrelationships will help determine the value and urgency of creating an archive for patient medical records.

Structural Process

The process of activating Medical Archive tools begins with obtaining source databases which contain the necessary medical records. Extracting and combing patient records and their related images, notes and other data is next. For testing purposes a selected sample of the records are used. The small number of records reduces staff time to validate the process. Once validated, all patient records are loaded into the Archive database. No edits are performed on the data and none of the data is reformatted. It is stored in the Archive database, “as is”. Data integrity is preserved as it exists in the source database. Thus the Archive is not “converted data”. In cases where original data content is required, a true Medical Archive is indispensable.

The final step in this structured process is to deliver the Archive database and Query programs for testing and validation.

Composition of Medical Archive files

The Archive contains all the data associated with each patient. It preserves relationships between data elements. It does not require nor maintain data dependencies. In other words, where a patient record is required to have an address associated with it, the Archive will contain all patient data even though the address may be incomplete or missing. Simply put, the Archive contains only the data that is provided in the source system.

Investigative Search

Before beginning any serious analysis it is necessary to determine what data is available. An investigation of the archived records will reveal their nature and relative content. Statistics are part of this investigation and can be a key in determining further analysis. When the object of the analysis is to determine trends, it may prove beneficial to perform data sampling before committing the analysis. On the other hand, when a complete set of records is required, the full data file is available.

Delivery

The Investigative Search can also be used to select records to be delivered to another party. Delivery can be electronically and/or hard copy. Patient records are requested for various purposes: medical referrals, patient request, legal summons. They can also be imported into an EMR system.

Archive Analysis

To begin an analysis, the Archive will first provide a means to reduce the pool of records. One example is to use a search criteria that eliminates records which do not meet that criteria. The search tools are relatively simple. They are designed to provide results which compass a refined set of records. Each smaller, more relevant collection of records can be filtered repeatedly. The goal is to deliver a focused record sets for further analysis. The analysis can be done by more complex analytical tools. Many are available from which to choose. They are commercially available. Each is designed with specific purposes in mind. Some will come with additional functions that provide for more relevant data selection and categorization. The selected Archive records are the raw data formatted for further evaluation.

Summary

The purpose of the Medical Archive is preserve and present data in its original form retaining its accuracy and completeness.

KW Norris is an IT professional, consultant and Sales Executive. KW works with medical clinics and medical software vendors to provide the best technology solutions available to improve quality and efficiency in the medical office. If you need a technology solution, KW can help you find it.

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