Communication is Key: Using the Outpatient Electronic Medical Record (OEMR) Messaging System to Communicate About Patient Care

2016 ◽  
Vol 16 (6) ◽  
pp. e19
Author(s):  
Mahesh Shrestha ◽  
Sonia Desikan ◽  
Lewis Krata ◽  
Emmanuel Unachukwu ◽  
Guiqing Huang ◽  
...  
Keyword(s):  
Patient Care ◽  
Medical Record ◽  
Electronic Medical Record

A Framework for Modelling the Electronic Medical Record

1993 ◽  
Vol 32 (02) ◽  
pp. 109-119 ◽  
Author(s):  
W. A. Nowlan ◽  
S. Kay ◽  
C. A. Goble ◽  
T. J. Howkins ◽  
A. L. Rector
Keyword(s):  
Decision Making ◽  
Patient Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Decision ◽  
Distributed Information ◽  
Aggregated Data ◽  
Direct Observations ◽  
Clinical Workstation ◽  
Specific Implementation

Abstract:This paper presents a model for an electronic medical record which satisfies the requirements for a faithful and structured record of patient care set out in a previous paper in this series. The model underlies the PEN & PAD clinical workstation, and it provides for a permanent, completely attributable record of patient care and the process of medical decision making. The model separates the record into two levels: direct observations of the patient and meta-statements about the use of observations in decision making and the clinical dialogue. The model is presented in terms of “descriptions” formulated in the Structured Meta Knowledge (SMK) formalism, but many of its features are more general than the specific implementation. The use of electronic medical records based on the model for decision support and the analysis of aggregated data are discussed along with potential use of the model in distributed information systems.

The Patient-centred Oncology Information System – Automating your Oncology Workflow For Optimal Patient Care

2012 ◽  
Vol 08 (04) ◽  
pp. 206 ◽  
Author(s):  
Peter Enever ◽  
Keyword(s):  
Information System ◽  
Radiation Therapy ◽  
Patient Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Critical Role ◽  
Advanced Treatment ◽  
Clinical Workflow ◽  
Treatment Techniques ◽  
Optimal Patient Care

Radiation therapy has become among the safest and most effective methods for treating cancer. Technology continues to play a critical role in managing and supporting advanced treatment techniques and ensuring safer practice. For clinicians, the ability to tailor the technology to meet their specific oncology workflows is a challenge. This article discusses how, by being able to automate clinical workflow in the electronic medical record (EMR), not only delivers greater department efficiency but can help support better outcomes through optimising patient care, before, during and after treatment.

scholarly journals Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers

2015 ◽  
Vol 23 (3) ◽  
pp. 544-552 ◽  
Author(s):  
William M Tierney ◽  
John E Sidle ◽  
Lameck O Diero ◽  
Allan Sudoi ◽  
Jepchirchir Kiplagat ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Health Centers ◽  
Hiv Care ◽  
Record System ◽  
Time Motion ◽  
Public Health Reporting ◽  
The Impact

Objective Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers. Method Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers’ satisfaction with the EMR. Results Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers’ work patterns, but the nurses’ and the clerks’ patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training. Conclusions We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses’ and the clerks’ patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow.

scholarly journals Enhancing Student Empathetic Engagement, History-Taking, and Communication Skills During Electronic Medical Record Use in Patient Care

2017 ◽  
Vol 92 (7) ◽  
pp. 1022-1027 ◽  
Author(s):  
Alisa Alfonsi LoSasso ◽  
Courtney E. Lamberton ◽  
Mary Sammon ◽  
Katherine T. Berg ◽  
John W. Caruso ◽  
...  
Keyword(s):  
Patient Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Communication Skills ◽  
History Taking

Development of Electronic Medical Record-Based “Rounds Report” Results in Improved Resident Efficiency, More Time for Direct Patient Care and Education, and Less Resident Duty Hour Violations

2016 ◽  
Vol 82 (9) ◽  
pp. 853-859 ◽  
Author(s):  
Phillip B. Ham ◽  
Toby Anderton ◽  
Ryan Gallaher ◽  
Mike Hyrman ◽  
Erika Simmerman ◽  
...  
Keyword(s):  
Patient Care ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Academic Medical Centers ◽  
Educational Activity ◽  
Direct Patient Care ◽  
Activity Time ◽  
Medical Centers ◽  
Academic Medical ◽  
American Board Of Surgery

Surgeons frequently report frustration and loss of efficiency with electronic medical record (EMR) systems. Together, surgery residents and a programmer at Augusta University created a rounds report (RR) summarizing 24 hours of vitals, intake/output, labs, and other values for each inpatient that were previously transcribed by hand. The objective of this study was to evaluate the RR's effect on surgery residents. Surgery residents were queried to assess the RR's impact. Outcome measures were time spent preparing for rounds, direct patient care time, educational activity time, rates of incorrect/incomplete data on rounds, and rate of duty hour violations. Hospital wide, 17,200 RRs were generated in the 1-month study. Twenty-three surgery residents participated. Time spent preparing for rounds decreased per floor patient (15.6 ± 3.0 vs 6.0 ± 1.2, P < 0.0001) and per intensive care unit patient (19.9 ± 2.9 vs 7.5 ± 1.2 P < 0.0001). The work day spent in direct patient care increased from 45.1 ± 5.6 to 54.0 ± 5.7 per cent ( P = 0.0044). Educational activity time increased from 35.2 ± 5.4 to 54.7 ± 7.1 minutes per resident per day ( P = 0.0004). Reported duty hour violations decreased 58 per cent ( P < 0.0001). American Board of Surgery in Training exam scores trended up, and estimates of departmental annual financial savings range from $66,598 to $273,141 per year. Significant improvements occur with surgeon designed EMR tools like the RR. Hospitals and EMR companies should pair interested surgeons with health information technology developers to facilitate EMR enhancements. Improvements like RRs can have broad ranging, multidisciplinary impact and should be standard in all EMRs used for inpatient care at academic medical centers.

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