Medical Records Management |

Image credit: Health Minister Dr. Zaliha visiting HKL on March 17, 2023, BERNAMA 2023

The Health Ministry of Malaysia has announced that it will allocate funds to the Kuala Lumpur Hospital (HKL) to digitalize patients’ medical records.

Currently, HKL as one of the country’s largest and busiest hospitals manages patient records manually and deals with over 16,000 records daily.

The move to digitize these records is expected to help HKL manage patients and their medical records more efficiently.

Speaking to reporters after the launch of “Buku Coffee Table Covid-19” at HKL, on March 17, Health Minister Dr. Zaliha Mustafa, who previously served at HKL as a medical doctor, stated that digitalizing patients’ medical records would be a great help to the hospital, and the Ministry would provide a special allocation for this purpose. However, Dr. Zaliha did not provide any specifics about the allocation.

Earlier, HKL Director Datin Dr. Rohana Johan expressed her desire to see all medical records digitalized for better management of the hospital and patients. She noted that around 16,000 patients’ medical records move in and out of Wisma Kayu—a building near HKL’s maternity hospital, nicknamed “Wisma Kayu” for its wooden infrastructure where all these records are kept, on a daily basis.

Dr. Rohana hoped that at least half of the records would be digitized before her retirement.

Paper documents have carried the medical industry for centuries.

Not too long ago before the rise of technology, paper medical records were the standard, and when managing medical records was a straightforward process of storing thick, color-coded paper charts in filing cabinets or on office shelves.

Even though paper medical records have enlivened the medical sector and brought about a quantum leap in patient care, they still have some shortcomings that cannot be overlooked.

However, for a lot of hospitals worldwide, paper records are all they’ve ever known.

Thus, it was a common scene when bundles of medical records were transported internally by Medical Records or other approved hospital staff. Although this practice has not gone away, it can still be seen happening in hospitals, especially in developing and less developed countries.

In the healthcare field, change is the only constant—something that we cannot avoid.

As practices have evolved and diagnostics and analytical tools have advanced, medical records management has also rapidly changed. Hospitals are now generating and retaining more patient information than ever before, including paper and electronic records.

In these situations, the barriers to switching to an Electronic Medical Record(EMR) are significant, like migrating archives that normally date back decades and hospital practices that would need to learn about EMRs, before they can start evaluating potential products.

All that to say, sticking with tried-and-true paper methods is appealing to a lot of providers.

Nonetheless, the EMR phenomenon has revolutionised healthcare. Healthcare providers are all too busy making a shift from dealing with mountains of paperwork to, for example, using touch panel PCs to maintain EMRs using the mobility of medical carts, which allows doctors to access and update patient records at the point of care with ease, instead of spending time digging through stacks of paper or staff carrying around paper-based medical records to reach the bedside.

Although we see change, I dare say that to this day, paper-based records aren’t completely obsolete, and many healthcare facilities worldwide are still using paper-based records only.

Many still are using a combination of paper-based and digital documentation using EMRs.