Clinical documentation is characterized by voluminous data and documentation as well as a high heterogeneity of archival content. On average, inpatient treatments produce more than 50 pages of single paper documentation per case. Assuming these are mostly A4 sized sheets of paper, a hospital or medical centre attending to 100 cases a day will result in 5,000 sheets of paper to be stored and archived by the medical records department daily!
In hospitals and other healthcare institutions the following types of documentations are archived:
1. Medical Records
All patient related documents like referral letters, medical findings, pictures, signals, videos, accounting documents.
2. Operational patient independent administrative documents
Those contain documents for administrative processes like financial accounting, personnel management, materials management etc.
3. Technical documents
These are the documentation of buildings, facilities, medical devices etc. office documents
4. Research documents
These are documents for clinical studies as well as other medical research documents.
5. Marketing and Patient Education material
These include posters, brochures, videos files (mp4 & mpg) or podcasts that will be viewed or consumed by patients and public visitors. The information can serve as reference or advice regarding diseases, symptoms and their treatments (medication/drugs/procedures). These will help sell the hospitals services.
The above situation presents the need to automate, manage and preserve such content with an IT-based system. Here is where Datamation (M) Sdn. Bhd. comes in with a full-fledged enterprise level content management system called EASY SOFTWARE.
Features of EASY SOFTWARE
1. Archival of well-defined, long-term stable and standard data formats
Even though EASY SOFTWARE readily archives any electronic document no matter the file format, in the healthcare industry we recommend the standard TIFF, PDF, PDF/A, JPEG, JPEG2000 and DICOM formats. Each format has its advantages in terms of minimizing storage size (compression) and system readability.
Text data based formats such as PDF and MS Office files can even have its content searchable using EASY SOFTWARE's full-text search capabilities.
2. Assurance of data privacy and data security requirements
Medical records and other documents are treated as confidential by default and access to them are controlled tightly via user roles and system permissions. Additionally, EASY SOFTWARE's fine-grained permissioning controls allow access to be granted/denied based on the value stored within the document's index. This is called Content Related Permissions.
3. Warranting correctness and protection against modification
4. Evidentiary value of digitally produced documents
Documents such as patient consent forms for procedures and treatments need to be signatured and legally acceptable. Traditionally this is paper based, however Datamation provides an e-form based solution whereby patients may sign on a tablet device, then timestamp and an encrypted e-signature from certified authorities will then be applied to the consent form.
Totally paperless, these documents and their corresponding certificates are readily retrievable from EASY SOFTWARE archives.
5. Long-term automated disposition of records
The EASY Archival engine applies a highly configurable Retention Policy to each and every document. In the case of Medical Records, the hospital might decide to dispose of records that are more than 7 years since the patient's last visit date. The system does this automatically based on the Retention Policy settings and may even selectively select a sub-set of the documents within a single Medical Record (MRN), e.g. cardiological records, to be transferred to a different storage medium such as LTO magnetic tape.
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