Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: An Iranian case study

2008 ◽  
Vol 24 (04) ◽  
pp. 445-451 ◽  
Author(s):  
Faramarz Pourasghar ◽  
Hossein Malekafzali ◽  
Sabine Koch ◽  
Uno Fors
Keyword(s):  
Information Technology ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Medical Information ◽  
Influential Factors ◽  
Ease Of Use ◽  
Medical Documentation ◽  
Care Providers ◽  
Medical Records System

Objectives:Information technology is a rapidly expanding branch of science which has affected other sciences. One example of using information technology in medicine is the Electronic Medical Records system. One medical university in Iran decided to introduce such system in its hospital. This study was designed to identify the factors which influence the quality of medical documentation when paper-based records are replaced with electronic records.Methods:A set of 300 electronic medical records was randomly selected and evaluated against eleven checklists in terms of documentation of medical information, availability, accuracy and ease of use. To get the opinion of the care-providers on the electronic medical records system, ten physicians and ten nurses were interviewed by using of semi-structured guidelines. The results were also compared with a prior study with 300 paper-based medical records.Results:The quality of documentation of the medical records was improved in areas where nurses were involved, but those parts which needed physicians' involvement were actually worse. High workloads, shortage of bedside hardware and lack of software features were prominent influential factors in the quality of documentation. The results also indicate that the retrieval of information from the electronic medical records is easier and faster, especially in emergency situations.Conclusions:The electronic medical records system can be a good substitute for the paper-based medical records system. However, according to this study, some factors such as low physician acceptance of the electronic medical record system, lack of administrative mechanisms (for instance supervision, neglecting physicians and/or nurses in the development and implementation phases and also continuous training), availability of hardware as well as lack of specific software features can negatively affect transition from a paper-based system to an electronic system.

scholarly journals Implementation of a single sign-on system between practice, research and learning systems

2017 ◽  
Vol 26 (01) ◽  
pp. 306-312 ◽  
Author(s):  
Saptarshi Purkayastha ◽  
Judy W. Gichoya ◽  
Abhishek Siva Addepally
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Medical Records ◽  
Ease Of Use ◽  
Practice Research ◽  
Care Providers ◽  
Clinical Workflow ◽  
Hospital System ◽  
Single Sign On ◽  
Medical Records System

SummaryBackground: Multiple specialized electronic medical systems are utilized in the health enterprise. Each of these systems has their own user management, authentication and authorization process, which makes it a complex web for navigation and use without a coherent process workflow. Users often have to remember multiple passwords, login/logout between systems that disrupt their clinical workflow. Challenges exist in managing permissions for various cadres of health care providers. Objectives: This case report describes our experience of implementing a single sign-on system, used between an electronic medical records system and a learning management system at a large academic institution with an informatics department responsible for student education and a medical school affiliated with a hospital system caring for patients and conducting research.Methods: At our institution, we use OpenMRS for research registry tracking of interventional radiology patients as well as to provide access to medical records to students studying health informatics. To provide authentication across different users of the system with different permissions, we developed a Central Authentication Service (CAS) module for OpenMRS, released under the Mozilla Public License and deployed it for single sign-on across the academic enterprise. The module has been in implementation since August 2015 to present, and we assessed usability of the registry and education system before and after implementation of the CAS module. 54 students and 3 researchers were interviewed.Results: The module authenticates users with appropriate privileges in the medical records system, providing secure access with minimal disruption to their workflow. No passwords requests were sent and users reported ease of use, with streamlined workflow.Conclusions: The project demonstrates that enterprise-wide single sign-on systems should be used in healthcare to reduce complexity like “password hell”, improve usability and user navigation. We plan to extend this to work with other systems used in the health care enterprise.

scholarly journals Benefit-risk of Patients' Online Access to their Medical Records: Consensus Exercise of an International Expert Group

2018 ◽  
Vol 27 (01) ◽  
pp. 156-162 ◽  
Author(s):  
Harshana Liyanage ◽  
Siaw-Teng Liaw ◽  
Emmanouela Konstantara ◽  
Freda Mold ◽  
Richard Schreiber ◽  
...  
Keyword(s):  
Health Care ◽  
Medical Informatics ◽  
Medical Records ◽  
Panel Discussion ◽  
Care Quality ◽  
Care Providers ◽  
Consensus Statements ◽  
Online Access ◽  
The Impact

Background: Patients' access to their computerised medical records (CMRs) is a legal right in many countries. However, little is reported about the benefit-risk associated with patients' online access to their CMRs. Objective: To conduct a consensus exercise to assess the impact of patients' online access to their CMRs on the quality of care as defined in six domains by the Institute of Medicine (IoM), now the National Academy of Medicine (NAM). Method: A five-round Delphi study was conducted. Round One explored experts' (n = 37) viewpoints on providing patients with access to their CMRs. Round Two rated the appropriateness of statements arising from Round One (n = 16). The third round was an online panel discussion of findings (n = 13) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups. Two additional rounds, a survey of the revised consensus statements and an online workshop, were carried out to further refine consensus statements. Results: Thirty-seven responses from Round One were used as a basis to initially develop 15 statements which were categorised using IoM's domains of care quality. The experts agreed that providing patients online access to their CMRs for bookings, results, and prescriptions increased efficiency and improved the quality of medical records. Experts also anticipated that patients would proactively use their online access to share data with different health care providers, including emergencies. However, experts differed on whether access to limited or summary data was more useful to patients than accessing their complete records. They thought online access would change recording practice, but they were unclear about the benefit-risk of high and onerous levels of security. The 5-round process, finally, produced 16 consensus statements. Conclusion: Patients' online access to their CMRs should be part of all CMR systems. It improves the process of health care, but further evidence is required about outcomes. Online access improves efficiency of bookings and other services. However, there is scope to improve many of the processes of care it purports to support, particularly the provision of a more effective interface and the protection of the vulnerable.

scholarly journals 530 An Audit of Appropriate Documentation Following Urethral Catheterisation

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
I Dokubo ◽  
J Armitage
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Clinical Care ◽  
Medical Personnel ◽  
Urethral Catheter ◽  
Residual Volume ◽  
Urethral Catheterisation ◽  
Catheter Size ◽  
Medical Records System ◽  
Insertion Process

Abstract Introduction Urethral catheterisation is a procedure frequently done in the hospital by medical personnel. Appropriate documentation is necessary to ensure safe clinical care and to reduce the risk of litigation. Method We randomly reviewed electronic notes of patients seen by the on-call urology team who had a urethral catheter inserted in September 2020. Reviewing the trust’s guidelines, we considered that appropriate documentation should include reference to the following 10 items; indication, chaperone present, consent obtained, groin examination, catheter size, catheter type, insertion process, urine colour, water in balloon and residual volume were reviewed. Results A total of 50 patients were included. 72%(36/50) were inserted by a member of the urology team. Only 28%(14/50) had all 10 items documented. Indication for catheterisation was best documented at 94%(47/50) while presence of a chaperone and groin examination (i.e. presence of a foreskin and its replacement post-catheterisation) were the lowest at 44%(22/50). Conclusions This study shows there is low compliance to adequate documentation of urethral catheterisation. A ‘smart phrase’ has been developed for use with our Trusts electronic medical records system to assist clinicians with appropriate documentation. Clinicians that use the phrase ‘.icat’ are prompted to document all 10 requisite items. This uses the mnemonic i-CATHETAR [indication, Chaperone and consent, groin Assessment, Tube (catheter size and type), insertion process (Hard/Easy), urine Tint, Aqua in balloon, Residual volume]. A second audit cycle is currently being done to review the effectiveness of this intervention.

Psychological, Social and Technical Factors Influencing Electronic Medical Records Systems Adoption by U.S. Physicians: A Systematic Model

2020 ◽  
Author(s):  
Raghid El-Yafouri ◽  
Leslie Klieb ◽  
Valérie Sabatier
Keyword(s):  
United States ◽  
Health Care ◽  
Medical Care ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Service Providers ◽  
Financial Burden ◽  
The United States ◽  
Care Providers ◽  
Intention To Adopt

Abstract Background: Wide adoption of electronic medical records (EMR) systems in the United States can lead to better quality medical care at a lower cost. Despite the laws and financial subsidies by the U.S. government for service providers and suppliers, the adoption has been slow. Understanding the EMR adoption drivers for physicians and the role of policymaking can translate into increased adoption rate and enhanced information sharing between medical care providers. Methods: Physicians across the United States were surveyed to gather primary data on their psychological, social, and technical perceptions toward EMR systems. This quantitative study builds on the Theory of Planned Behavior, the Technology Acceptance Model, and the Diffusion of Innovation theory to propose, test, and validate an innovation adoption model for the health care industry. 382 responses were collected and data were analyzed via linear regression to uncover the effects of 12 variables on the intention to adopt EMR systems.Results: Regression model testing uncovers that government policymaking or mandates and other social factors have little or negligible effect on physicians’ intention to adopt an innovation. Rather, physicians are directly driven by their attitudes and ability to control, and indirectly motivated by their knowledge of the innovation, the financial ability to acquire the system, the holistic benefits to their industry, and the relative advancement of the system compared to others.Conclusions: A unidirectional mandate from the government is not sufficient for physicians to adopt an innovation. Government, health care associations, and EMR system vendors can benefit from our findings by working toward increasing the physicians’ knowledge of the proposed innovation, socializing how medical care providers and the overall industry can benefit from EMR system adoption, and solving for the financial burden of system implementation and sustainment.

The role of electronic medical records in improving the quality of health care services: Comparative study

2019 ◽  
Vol 127 ◽  
pp. 63-67 ◽  
Author(s):  
Omar Ayaad ◽  
Aladeen Alloubani ◽  
Eyad Abu ALhajaa ◽  
Mohammad Farhan ◽  
Sami Abuseif ◽  
...  
Keyword(s):  
Health Care ◽  
Comparative Study ◽  
Electronic Medical Records ◽  
Quality Of Health Care ◽  
Medical Records ◽  
Health Care Services ◽  
Care Services
Sign in / Sign up

Export Citation Format

Share Document