The use of paper records, a lack of uniformity in electronic medical records and the wildly varying quality of medical data collected poses risks to patient care, according to a Monash University study into medical records in Melbourne hospitals.
 
In an audit of medical records at five major university teaching hospitals, including one private hospital, the researchers found “discordance” in the medical information in the different hospitals’ systems, risking medication mistakes.
 
“In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This causes inefficiencies in the recall of patient information and can potentially lead to incidences of adverse drug events,” the authors wrote.
 
The research, ‘Electronic health records and online medical records: an asset or a liability under current conditions?’, published in Australian Health Review, recommends the implementation of medical history documentation guidelines and standardised discharge summaries in Australian healthcare services to help solve the problem.
 
“Of all medical records audited, 82 per cent contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49 per cent of records audited showed evidence the discharge summary was sent outside the institution,” the report authors write.
     
The study also recommends transition from paper and scanned medical records to a more complete, accurate and unified patient-centred EHR, and advocates for healthcare provider uptake of the Australian Digital Health Agency’s national My Health Record.
 
“The implementation of a solely electronic system that integrates hospital and GP records in a shared database for all healthcare workers will improve patient safety and has the potential not only to reduce healthcare costs, but also to improve healthcare quality.
 
“By using an [Individual Healthcare Identifier] and [MyHR], both currently available under Australian legislation, the management of emergency medical problems and complex cases may be improved in new patients when substantial medical information is held at another institution.”
 
However, the study cautions that the value of MyHR depends on the quality of information contained in clinical systems across the healthcare services.
 
For the research, the records of 40 randomly selected patients per hospital were studied to determine the quality of the record keeping, as well as storage and use across each hospital’s online clinical database, scanned files and paperwork.
 
The findings showed little uniformity in the electronic clinical information systems being used by healthcare providers. The data captured, stored and used was variable and dependent on the healthcare organisation, with the creation of information silos. Patient safety was found to be dependent on complete and efficiently collected health information.
 
“The current electronic databases are only as good as the information that is entered and are dependent on patient recall limitations and staff biases in deciding what is relevant to record.”
 
Absent data in the medical records and discharge summary information was especially concerning, the researchers said.
 
“It is clear that current electronic health systems are simply another tool that used properly can be an excellent asset, but if incorrectly used may be a significant liability.”
 
Lack of interoperability between different information sources also meant there was “no easily identifiable source of truth” in most of the healthcare providers studied, although Monash Health showed the benefits of an integrated system.
 
“At Monash Health the medical record and pharmacy database are linked and therefore 100 per cent concordant. These represent an ‘ideal’ model, where numerous systems are replaced by one that incorporates information from a range of sources and, in doing so, minimises the possibility of error.”
 
Other facilities that took part in the study were the Alfred, Box Hill, Frankston and Cabrini hospitals.
 
No guidelines currently exist across the healthcare system for medical history documentation or the distribution of discharge summaries to other healthcare providers such as GPs.
 
By the end of 2018 every Australian will have a MyHR unless they have opted out.