By permitting the destruction of paper originals and by shaping a legal framework for digital copying, the legislator definitively imposes dematerialisation in the medical landscape. For the time being, however, the majority of healthcare institutions are just scratching the surface. Indeed, which way to choose between the digital whole and the survival of a paper format that has not finished being useful ... and used?
Tribune libre by Simon OSTERMANN, Head of Healthcare at PRO ARCHIVES SYSTEMES
The nature of the medical record makes the problem of traceability extremely sensitive. All the more so as the archivists and the medical secretaries in charge of them have to deal not only with old and heterogeneous classifications, while respecting the durations of conservation, but also to manage the identitovigilance (system guaranteeing the patient a perfect identification During the course of care) and allow the patient to access his medical file as soon as possible. A real challenge.
Legislative and normative acceleration
Fortunately, essential texts have recently emerged to help them accelerate this digital transition. Thus, the decree of 5 December 2016 and the ordinances of January 2017 lay down precise rules on the reliable dematerialisation, destruction and accommodation resulting from it. The weight of evidence is now indifferent to the medium, whether the file is in paper or digital format. In order to confer reliability, the reproduction must take place identically to the form and content of the original, whether a timestamp and a qualified electronic signature are used; And that integrity is guaranteed over time (preservation of traces and electronic fingerprints). On the basis of this principle, the destruction of the original paper is authorized before the end of the legal period of preservation. This new regulatory framework is also concomitant with standard NF Z42-026 whose compliance with the specifications will lead to the deletion of the original paper. All this creates a new balance that allows healthcare professionals to redefine their archiving policy.
The decline of paper in the face of reality on the ground
The end of the paper will make it possible to resolve problems related to the integrity of medical data in the face of time wear, but also to their confidentiality in poorly secured archives, and to the shortage of space in premises unsuitable. If the decline of paper is now a reality, the migration to digital will be gradual for healthcare institutions. Some have already taken a first step thanks to the DPI (computerized patient record) for the files of MCO in particular; But this computerization does not concern 100% of medical records.
Obstacles and doubts to be lifted
The obstacles to complete digitization of the medical file remain, indeed, numerous. The psychological attachment to paper is supplemented by its frequent use for the needs related to the medical management of the patients (causing the printing of elements yet computerized), training agents on the new software (in a context of Overloading of work) or even the management of the answers of increasingly longer applications. So many constraints that stop this digitization.
Towards a mixed and controlled management
In order to respond pragmatically to the real needs of healthcare institutions, the solution lies immediately in a mixed management, mixing paper (less and less) and digitization (more and more). Most of the services have already tamed it. They must now be helped to see more clearly in the choices available to them and to develop relevant digitization, conservation or destruction strategies, depending on the nature of the archives and the pace of flows. Today, staff must be trained both in the management of native documents and in paper documents (which should be better classified to optimize time and space).
The quest for converging HIS
The answers are also technical, turned towards an efficient and homogeneous information system in order to avoid the cumbersome management of IS built on heterogeneous infrastructures. This is particularly true of the convergent hospital information system currently in place within the GHT (territorial hospital groups) required by the law of 26 January 2016 to modernize our healthcare system.
Ultimately, instead of digitizing, is it preferable to digitize the most hectic files in order to reduce paper flow, avoid traceability problems and extra costs, and thus make access to the files more Easy and fast?
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