An Institutional View of Electronic Records Management: Hospitals & Teleradiology

Article excerpt

Electronic records and recordkeeping systems are ubiquitous in most organizations. Only recently, though, have records professionals begun to realize their full power, potential, and uses. Electronic records have the power to capture ideas, notes, and communications that were previously invisible or ephemeral events such as fleeting face-to-face or telephone conversations.

Implementations of electronic recordkeeping systems can: (1) provide more people with greater access to information and (2) give them the possibility of putting disparate information together in new, innovative ways -- in essence to create new knowledge (Davenport and Prusak 1998). These two factors affect the appraisal of previously established records series, the way these series function in the workplace, and the expectations for the use of these records by different individuals. The legal and economic implications of such changes are only now emerging.

As more and more paper records take electronic form, records managers need to reassess and reanalyze the records with a careful examination of the new organizational communication patterns and functions that electronic recordkeeping systems support. This article examines the trends mentioned and cites as examples emerging applications in the medical arena, particularly in the area of radiology. It is founded on a research study at a large tertiary care medical center (Yakel 1997).

Traditional Radiological Records: The Generation Processes

Radiologists create and interpret images derived from a variety of modalities: radiography, ultrasound, magnetic resonance imaging (MRI), positron emission tomography (PET), and computed tomography (CT). These radiological processes of image creation and interpretation are bounded by the generation of records. A clinician writes a radiological requisition to begin the process; a signed radiologist's report signals its completion.

The most common records associated with radiology are the anatomical images themselves and the radiologist's report of findings -- the interpretation of those images. Radiological processes, though, encompass a number of records-creating events resulting in the creation of a variety of types of documentation.

These documents include a requisition for radiological services, scheduling calendars, the actual images generated, various forms of the report that may range from indexes to images to be viewed, notes in preliminary books, an audiotape of the report by the radiologist, the preliminary -- or unapproved -- version of the transcribed report, and the final, approved report.

Additionally, other types of records may also be used to inform the radiological interpretation, including the medical record, particularly any previous radiological images and reports. The radiological images and final reports are the focus of this article.

Although numerous doctors' offices have access to a basic radiography (X-ray) machine and perhaps ultrasound technology, these images still must be professionally interpreted by radiologists, who are often associated with area hospitals. Patients requiring imaging techniques, such as a MRI or CT scan, must go to a hospital or special center for these tests. Image capture, then, takes place at diverse locations, and in the latter scenario, the clinician does not have ready or easy access to the images and must rely primarily on the report when making a diagnosis.

In many hospitals, the radiological report has traditionally been created orally using a telephone dictation system. Clinicians would either telephone into the system to listen to a verbal, preliminary, and unauthorized report, or they could wait until the dictation was transcribed and then access an approved, written description and analysis of radiological images.

If clinicians wanted to tie the written report to the images, clinicians often had to request the images to study them in conjunction with the written report. …