Author: Neelam Sirichandana

Key points

• Medical data entry process is pivotal for quality healthcare among patients.
• Medical data entry processes promote the proper communication among the healthcare professionals which may strengthen the clinical decisions and decrease the risk of adverse events.
• Different steps are involved in the data entry process right from receiving the data to uploading in a secured software.
• Skilled personnel with sound medical knowledge are required for data input in the medical data entry process.
• Different softwares are used across the world for the process of medical data entry.

INTRODUCTION

Appropriate data is essential to support the proper workflow of any healthcare organization. Availability of suitable data aid for managing the operations easily. Recording and documentation is one of the ubiquitous sets of strategies, processes, and procedures applicable to all organizations. Documented information promotes quality health care.

In this era of technology in healthcare which is robust and widespread most of the healthcare institutions all over the world are implementing electronic technologies across all spectra of their clinical practices to enhance health information interchange. Although recording up medical data is pivotal responsibility, it is poorly practiced in India. Medical data includes administrative and demographic information, diagnosis, treatment, prescription drugs, laboratory tests, physiologic monitoring data, hospitalization, patient insurance, etc.³

Maintaining proper healthcare records enhances convenient communication between healthcare providers and it intensify clinical decisions which may further reduce the risk of prevalence of adverse events.Data entry at hospitals reduce the paperwork and help to manage the work at healthcare organizations more efficiently. The standards of the records reflect the standards of quality of health care provided.¹

The process of entering and organizing the data in an electronic device and transferring into appropriate database is called as medical data entry process⁴. Medical data entry process is usually performed by medical data entry specialists. They perform numerous processes such as clerical and administrative activities in medical management.⁶

The vital task of a data entry specialist is entering data into a health information system. Other commitments include the collection of data from various units and departments, maintaining electronic health records, running reports, and filling paperwork. (12) Trained data entry specialist enters the data, more efficiently.⁷

DIFFERENT SOFTWARES USED IN MEDICAL DATA ENTRY PROCESS:

1. HealthPlix EMR
2. DocPulse
3. Docon
4. Praxify
5. Medanta EMR
6. KareXpert
7. Practo Ray
8. Notation Matrix
9. Fusion Web Clinic
10. Napier Healthcare Solution⁸

STEPS INVOLVED IN DATA ENTRY PROCESS

Fig 1: steps involved in data entry process

1. RECEIVING THE HARDCOVER OF THE DATA THROUGH EMAIL OR SERVER: The raw data, including patient details such as name, date of birth, insurance details, address, medical history, etc., is received from different healthcare institutions through different software. The data is received through safe and encrypted mediums.
2. GATHERING UP THE REQUIRED DATA THROUGH VARIOUS INPUTS AND DATA ENTRY: After receiving all the raw data, the data that needs to be uploaded is gathered together. For gathering up the data, different inputs are used. In this step of the data entry process for medical records, the incorrect and missing information is reported back to the sender of the data. And finally, the accurate data is entered

1. CATEGORY AND CLASSIFICATION OF THE DATA ENTERED: The data that is gathered is classified based on the requirements. In this step of data entry processing, the data that is not required to be stored is omitted.¹³
2. STORING THE DATA IN THE REQUESTOR’S FORMAT IN AN ORGANIZED WAY: The data that is finalized to store is formatted in an organized way in the requestor’s format and stored.
3. CHECKING FOR QUALITY AND ACCURACY: it includes a step called validation. Validation is a process of checking that is performed during the medical data entry process. It is usually executed to know whether the data that is accepted is sensible and reasonable in the way in which it is being used. Validation is performed by a computer and consists of a series of checks called validation checks. Two types of validations are performed, which include 1. Analytical validation 2. Clinical validation.¹¹

• UPLOADING THE DATA INTO A SECURED DATABASE: The data before uploading is sent to the client or requestor to check for format and requirements and is then requested to be finalized. The finalized data is uploaded to a secured database

ADVANTAGES:

• High-quality services: Different healthcare professionals and organizations can focus on providing quality healthcare services, whereas the experts operate the data entry services.⁵
• Reduction of errors: Medical data entry services provide the service of making patient data available at one point, which includes information about demographic details, past medical history, past medication history of the patient, and allergic history of the patient, which further leads to the reduction of errors while prescribing the medication.
• Easy access to information: Through electronic health data, healthcare providers can easily access the database to retrieve information about the patient.
• Reducing the paperwork: Maintaining the paper-stored information is a cumbersome process; medical data entry promotes the digitalization of the data, which is also environmentally friendly. It also reduces the requirement for skilled personnel and eliminates the requirement for printing the data.
• Effective medical data management: Medical data entry promotes the efficiency of data management, as the data entry processing is performed by skilled medical data entry specialists, and the data will be input, indexed, and instantly retrievable by any authorized user. And the data can be stored at various locations where it can be accessed by different healthcare professionals.
• Promotes patient care: As complete information about patients is available in one place, the focus on the patient is increased, allowing for an in-depth analysis of the patient’s health status, which promotes overall patient care.

Cost-diminishing: Digitization of documents enables a provider to get rid of physical documents, which preoccupy resources such as space, security personnel, and a decay-free environment.

Fig 2: paperwork of health care records

• Potential Privacy and Security Issues: Privacy and security issues may arise due to the medical data entry process, as the data is prone to hacking, by which highly sensitive data may fall into unethical hands. ⁹
• Inaccurate Information: As the nature of the health care records is that they need to be updated more frequently regarding the visits by the patient, the negligence in updating the information may aid the health care providers in relying on irrelevant data in making decisions regarding treatment protocols.
• Frightening Patients Needlessly: As the electronic health data promotes the setup in which the patient can access his or her own medical data, there is a tendency for misinterpretation of data, which can create false alarms and panic within the patient.
• Malpractice Liability Concerns: In the process of data entry, malpractice is a concern.⁹ If the data is known to have undergone malpractice, it could lead to legal problems¹⁴.
• Requirement of skilled personnel: For the medical data entry process a skilled personnel with good qualifications is required, sometimes it is difficult to obtain a skilled personnel for the data entry¹¹

CONCLUSION:

In this era of high technology, the importance of medical data entry process should be highlighted in the health care system and its role in patient care should be considered. We can expect a fall over in the incidence of errors in healthcare setup with the medical data entry process. Rather than relying on skilled personnel for the data input, the physician should be considered as they prevent entry errors as they have good knowledge of medical terminology and can have easy access over patient information while taking therapeutic decisions and to plan treatment protocols. India needs to be encouraged to promote the medical data entry process to promote the patient safety. As the digitalization of medical data has more assets than liabilities, it should be promoted and practiced all over the world

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