Practice Brief: Managing Multimedia Medical Records: A Health Information
Manager's Role
Background
Health information has been undergoing major change during the past several
years. The entire concept of what health information is has been redefined.
Accordingly, health information managers need to take on diverse roles that
support new information management tasks. Managing the use or creation of
a multimedia medical record is a natural progression for health information
professionals. Some of the issues that surround the creation of today's
medical records are:
- What is health information management?
- How do I incorporate multimedia data?
- How do I make the transition?
Health Information Management
Medical record management expanded into health information management in
conjunction with the advancement of new technologies. Medical records are
no longer just made up of discharge summaries, progress notes, physician's
orders, and flow sheets. Online reports from the laboratory and pharmacy,
x rays, photographs, videotapes, films, and audio recordings are all part
of the clinical data gathered about patients. Information that is generated
about patients in healthcare facilities -- regardless of the medium-should
all be classified as part of the medical record.
Not only is health information management collecting the patient data
at a facility, it is protecting it, interpreting it, and analyzing it
to make decisions. So incorporating different pieces of data to create
a medical record is today's new challenge. Uses of medical records or
health information vary from basic patient healthcare to facility accreditation,
from quality improvement trending to medical research and education. These
-- and all potential uses of health information -- require that the most
current and complete information is available. The fact that health data
is now created in multiple forms of media is what makes the health information
professional's job challenging.
Multimedia Data Formats
The paper record is still the most common form of medical record. However,
today's "paper" record can be dissected to find other media formats within
the paper world. Many facilities already have electronic laboratory and
pharmacy systems that allow online viewing of patient information. And paper
record environments demand that printouts of patient data be placed in the
patient medical record. Besides paper, another medium typically found in
a paper record is the monitoring strip. These strips generally are filed
in the chart, affixed to paper or in folder pockets. Sample portions of
monitoring strips also may be mounted to the medical record, with the entire
strip stored separately. Photographs may also find their way into a medical
record. However, there are other data forms that need to be addressed in
order to create the most complete and thorough medical record.
Videotapes, audio recordings, x rays, and other media output forms should
be considered part of a patient's medical record. Yet this creates obstacles
in a paper environment since these types of media generally cannot be
filed in a standard paper medical record. Health information managers
need to look at this challenge and find the ways and means to bring all
patient health information together -- creating a complete and complex
patient health record. Following are some steps to take in the quest to
bring all patient health information together, regardless of media output:
- Look at the current composition of medical records in your facility
- Decide if all patient health information is being collected and managed
uniformly
- Evaluate what patient data, if any, is not incorporated in a medical
record
- Determine how information that is generally not filed in medical records
is obtained and released when it is needed. Do these procedures ensure
confidentiality?
- Determine storage requirements for information currently not filed
in the medical records
- Meet with staff involved in the management of the health information
data that is not filed with the medical record
- Offer to coordinate efforts to bring all pieces of health information
together to create one complete multimedia medical record
Incorporating Multimedia Data Formats
Incorporating different forms of multimedia data can be done in various
ways. A computer-based patient record at a facility can serve as or can
actually create a multimedia medical record. When computerized medical
records are implemented at a facility, different media formats can be
captured together. By evaluating what patient data a facility generates
and matching that with a vendor's electronic medical record product, a
multimedia medical record can be created. When all media formats are stored
together with other patient data under a unique patient identification,
a comprehensive medical record is achieved.
Since most facilities do not have electronic medical record capabilities
currently, health information professionals need to be resourceful when
incorporating multimedia data formats with basic patient data. Microfilm
and microfiche records are examples of medical record formats that most
health information professionals are familiar with. However, videotapes,
audio recordings, films, photographs, and x rays may not be considered
typical formats for medical records. It is the responsibility of the health
information professional to inform and educate other departments on the
importance of these valuable pieces of data in health information management.
Making the Transition
Aside from implementing a complete electronic medical record for your facility,
creating a multidisciplinary team to address the issues related to multimedia
medical records is essential. The health information professional should
organize the team and act as a visionary. One of the team's main goals should
be to develop an incorporation plan. The plan should list the patient data
that needs to be incorporated to create a complete medical record. The plan
should also identify policies and procedures on creating and managing a
multimedia medical record. This team also can aid in the identification
of issues and the creation of solutions surrounding multimedia medical records
as they arise.
Acceptance and space may be two issues that health information professionals
encounter. Different departments may not agree that their film or x rays,
for example, should be considered part of the medical record. Meeting
with department staff and discussing the benefits of incorporating their
patient data may persuade them to change their minds. Working this topic
out with the multidisciplinary team will help open doors to the acceptance
of combining multimedia formats for a complete medical record.
The issue of space becomes a problem when different multimedia formats
need to be stored in a medical record department. Most departments are
already deprived of space. Adding more patient data to a record or department
in various multimedia formats may not be feasible in the space currently
allocated to store and manage medical records. Space and storage reorganization
may need to become part of the incorporation plan. A multidisciplinary
team also may help tackle problems concerning space with ideas on overcoming
space limitations.
Prepared by
Jennifer E. Carpenter, RRA, HIM practice associate
Acknowledgements
Assistance from the members of AHIMA's Professional Practice Division is
gratefully acknowledged.
Issued: February 1998
|