Digital Preservation and Management of Medical Records: Towards Modernizing South African Medical Record Libraries in the Technology-Driven Era

Introduction

The world should have a healthy population and therefore, medical/health records are the projections of an individual’s health over time. A good medical record serves the interest of the medical practitioners as well as patients and it is thus very important for the treating doctor to properly document the management of the patient under his care (Bali et al, 2011). Mogli (2009) described health record as an important document that is used by healthcare institutions and practitioners to record patient history, illness and treatment. It is created as evidence of an interaction between patient and healthcare practitioners during a patient’s visit to a healthcare facility. Bali et al (2011) further described a health record as a document that contains complete and accurate description of a patient’s history, conditions, diagnostic and therapeutic treatment and the results of treatment. Health record thus involves the orderly written document encompassing the patients’ identification data, health history, physical examination findings, laboratory reports, diagnosis, treatment and surgical procedures and hospital courses (Judson & Harrison, 2010). Medical records are used in the management and planning of health care facilities and services, for medical research and the production of health care statistics (Judson & Harrison, 2010). These records are usually summoned in a court of law in certain cases like-road traffic accident, medical negligence, insurance claim etc. (Singh, Sinha & Sharma, 2005). However, the medical records that are no longer required can be destroyed under the guidance of the retention and disposal document.

The dramatic changes to digital world have led to the creation of digital or electronic records within the libraries including medical records libraries, worldwide. In most developed countries, medical records are stored in the main hospital designated medical/health records library. Medical records libraries create and store huge volumes of records concerning citizens, patients, medicines, biomedical equipment, scientific knowledge, the operation of facilities. Opele, Omele and Adebayo (2019) described medical records library as a building in a health institution where patients’ case notes are stored for planning, research and for effective treatment of the various ailments. These libraries are established for tracking system so as to ensure the location of every set of case notes is recorded and are available for use at every episode of care to eliminate possible clinical risk (Opele, Omele & Adebayo, 2019), while also ensuring that they serve the information needs of medical communities like healthcare professionals, physicians, medical researchers, students, and patients.

Medical records libraries are using filing shelves that are organized in a way that will foster a positive and safe work environment for the health care workers allowing them to render services for effective patient service delivery (Opele, Omele & Adebayo, 2019). Medical professional’s daily duties, dealing with health conditions and research depend on access to authentic information and it is critical that access to such information is user friendly and time saving. Medical records must be accurate and authentic, in order to facilitate ongoing diagnoses and to help health care professionals provide patients with the most appropriate treatment. Ashiq, Rehman and Mujtaba (2021) argued that rapid, dynamic and innovative changes in the technological sector and globalization continue to drive the digital revolution in libraries. The adoption of modern technologies is changing every aspect of the library, for example, acquisition, processing, storage, retrieval and dissemination of information. Therefore, today's library information services provision ensures long-term access to digital records, however, there can be a delay or no access to these records if they are not properly managed and preserved. When record is poorly organized and managed, it results in the difficulty to access it and probably loss of digital records, and when there is no proper access to relevant information it can result in inefficiency in the provision of services. Valuable health records need to be organized, digitized, preserved and managed in a way that there is ease of access and dissemination. A good health records management thus requires adequate attention to its preservation and conservation for the benefits of the patients, care providers and the hospital.