Maintaining a Standardized Electronic Registry of Spinal Cord Injury in the Public Sector: Recommendations and Legal Implications

Introduction

Health record of a person should document each of his health-related events and these records should be available in a longitudinal fashion arranged in a timeline so that it provides summary of health-related events in the life of that person. Even though each of the health-related events may or may not be related to the current medical problem encountered by person it should be documented so that it can be corelated if another health-related event happens in future. Meaningful health care data that is generated round the clock will have a long-term clinical relevance so that it provides better evidence-based care, accurate and rapid diagnosis, low-cost care avoiding unnecessary repetition of medical investigation. It will thus predict future ailments leading to better personal and public health following improved government policy based on health records. Proper standards must be maintained in retrieving information, its storage, retrieval, exchange of information among physicians. There should be adequate software to store and share images.

The legal implications of maintaining medical records are described in detail along with the legal liability in case of improperly maintained records is described in this chapter. The need for spinal cord injury registry and the importance of maintaining an electronic registry and data base is also highlighted. The problems of electronic medical records like data inaccuracies, data breaches are described along with possible solutions and future recommendation are included. The author like to conclude that we need to link multiple hospital-based registries and introduce centralized and standard reporting methods for maintaining and monitoring a medical record database system so that patient records are retrievable within split of a second. The data available should be used for the betterment of patient and the society but at the same time avoiding data breaches and maintaining patient privacy and confidentiality

The chapter provides overview of the type of medical records, problems with paper-based records, the need for electronic data base and registry of spinal cord injury. The key standards on how to maintain data information and retrieval system and the recommendation and future research on this area for improving patient care are described. A detailed future recommendation on the interoperability standards, clinical informatics standards, standards of data ownership, privacy and security issues and their ethical and legal issues are also addressed

This chapter provides a set of recommendations for adoption of electronic health informatics standards in medical records management. Despite identifying, the problems with existing medical record system and problems with paper-based records, the chapter provides a short anecdotal guideline-for-implementation change in the existing field of medical records. It is reiterated that with adoption of these standards, the data retrieval, storage, transmission will be standardized to levels that will reduce inter operator variability of data contained in the records. This chapter does not deal with implementation part such as of administrative or regulatory aspects but provides insight into the liability and legal implication of not properly maintain medical records. Quality health delivery is not merely providing safe and sustainable care to the patients but also in proper maintenance of medical records. It is very difficult for health care providers to decide on the treatment plan if there are no accurate, legible, and updated medical records.

The purpose of maintaining electronic medical records is to store the details of patient’s case history and personal details in the cloud space so that complete information regarding the treatment plans, follow-up is retrievable within split of a second. Electronic medical records are a good communication tool for referring patients among health care providers respecting patient confidentiality and privacy (Cripps, 2011). The medical records will also be useful for analysis and self-improvement of health care providers so that they can have a self-realization regarding the service they are providing to needy patients (Singh, 2003). The statistical data regarding patients are not only useful for hospitals but also to government agencies for health policy making.