The importance of patient records has been recognized as far back as the 5th century BC, when father of medicine Hippocrates advocated their use in recording the course and possible causes of disease.
The emphasis of modern day medical records was established early last century, and more recently a shift from paper records to electronic patient records (EPRs) has been underway.
Integrated electronic patient records
At Poria Hospital, the case study location, patient information is recorded in a SAP system with integration across systems such as laboratories, radiology, obstetrics and gynecology imaging, and finance and accounting. The SAP system is linked to a data warehouse where external medical centres can both access and contribute patient information.
Electronic patient records are stored in central servers with disaster backup and firewall protection. Studies have shown no meaningful difference in the time involved in preparing paper versus electronic records.
From 2012, Israeli Government hospitals have been introducing a Health Information Exchange (HIE) system which collects patient information from most hospitals and makes it available to medical professionals. Safeguards are in place to control access to the information and prevent its misuse.
The need for a permanent patient identification number
In Neonatal Intensive Care Unit (NICU) departments there is a risk of patient misidentification due to factors such as similar names or dates of birth.
To address this, patient identification numbers (PIDs) are assigned. To overcome the potential problems of trying to work with identification numbers created across diverse systems, national identity numbers are used as PIDs, or for visitors their passport number is used.
To ensure that babies have a PID as early as possible, they are required to be assigned within two hours of birth.
Triplets were born prematurely by emergency cesarean section. The use of EPRs and PIDs meant that medical staff in the NICU had information pertaining to the babies before they were actually transferred from the delivery room.
During their hospitalization, the babies required surgery at another hospital. Making their records available meant that the babies could receive treatment without delay or further testing, and the same occurred when they returned to Poria hospital and again later when they were discharged to community care.
The paper authors conclude that:
…the more accurate the patient identity numbers are with little or no changes at all, the less likely there will be files mismatched or misplaced. Furthermore we express the importance of data warehouses and data sharing to make medical records available from across health systems and locations thus eliminating unnecessary and duplicate tests as well as provide necessary information as it is needed from the very first moments of life.
- Kushnir, A., Rubin, R., Chulsky, E., Zohar, D. and Barak, S. (2015). When Knowledge Management and the Neonatal Intensive Care Unit Add Up to a Triplet Success Story. Primary Health Care 5: 205. doi:10.4172/2167-1079.1000205 ↩