Completeness of doctor note in electronic health record system in primary health care unit

2017 ◽  
Vol 10 (1) ◽  
pp. 274
Author(s):  
Won Sriwijittala ◽  
Viroj Wiwanitkit
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Electronic Health Record ◽  
Electronic Health Record System ◽  
Health Record ◽  
Record System ◽  
Primary Health ◽  
Health Care Unit ◽  
Electronic Health

scholarly journals How well is the electronic health record supporting the clinical tasks of hospital physicians? A survey of physicians at three Norwegian hospitals

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Thomas Roger Schopf ◽  
Bente Nedrebø ◽  
Karl Ove Hufthammer ◽  
Inderjit Kaur Daphu ◽  
Hallvard Lærum
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Electronic Health Record System ◽  
System Stability ◽  
Medical Decision ◽  
Health Record ◽  
Clinical Workflow ◽  
Online Questionnaire ◽  
Record System ◽  
Electronic Health

Abstract Background The electronic health record is expected to improve the quality and efficiency of health care. Many novel functionalities have been introduced in order to improve medical decision making and communication between health care personnel. There is however limited evidence on whether these new functionalities are useful. The aim of our study was to investigate how well the electronic health record system supports physicians in performing basic clinical tasks. Methods Physicians of three prominent Norwegian hospitals participated in the survey. They were asked, in an online questionnaire, how well the hospital’s electronic health record system DIPS supported 49 clinical tasks as well as how satisfied they were with the system in general, including the technical performance. Two hundred and eight of 402 physicians (52%) submitted a completely answered questionnaire. Results Seventy-two percent of the physicians had their work interrupted or delayed because the electronic health record hangs or crashes at least once a week, while 22% had experienced this problem daily. Fifty-three percent of the physicians indicated that the electronic health record is cumbersome to use and adds to their workload. The majority of physicians were satisfied with managing tests, e.g., requesting laboratory tests, reading test results and managing radiological investigations and electrocardiograms. Physicians were less satisfied with managing referrals. There was high satisfaction with some of the decision support functionalities available for prescribing drugs. This includes drug interaction alerts and drug allergy warnings, which are displayed automatically. However, physicians were less satisfied with other aspects of prescribing drugs, including getting an overview of the ongoing drug therapy. Conclusions In the survey physicians asked for improvements of certain electronic health record functionalities like medication, clinical workflow support including planning and better overviews. In addition, there is apparently a need to focus on system stability, number of logins, reliability and better instructions on available electronic health record features. Considerable development is needed in current electronic health record systems to improve usefulness and satisfaction.

scholarly journals Information systems and the electronic health record in primary health care

2007 ◽  
Vol 15 (3) ◽  
pp. 187-192
Author(s):  
Milica Katić ◽  
Dragan Soldo ◽  
Zlata Ozvačić ◽  
Sanja Blažeković-Milaković ◽  
Mladenka Vrcić-Keglević ◽  
...  
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Information Systems ◽  
Electronic Health Record ◽  
Health Record ◽  
Primary Health ◽  
Electronic Health

scholarly journals Narrative Review for Exploring Barriers to Readiness of Electronic Health Record Implementation in Primary Health Care

2019 ◽  
Vol 25 (3) ◽  
pp. 141 ◽  
Author(s):  
Sandra Hakiem Afrizal ◽  
Achmad Nizar Hidayanto ◽  
Putu Wuri Handayani ◽  
Meiwita Budiharsana ◽  
Tris Eryando
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Electronic Health Record ◽  
Narrative Review ◽  
Health Record ◽  
Primary Health ◽  
Electronic Health

scholarly journals Implementing an Open Source Electronic Health Record System in Kenyan Health Care Facilities: Case Study

2018 ◽  
Vol 6 (2) ◽  
pp. e22 ◽  
Author(s):  
Naomi Muinga ◽  
Steve Magare ◽  
Jonathan Monda ◽  
Onesmus Kamau ◽  
Stuart Houston ◽  
...  
Keyword(s):  
Health Care ◽  
Electronic Health Record ◽  
Open Source ◽  
Health Care Facilities ◽  
Electronic Health Record System ◽  
Health Record ◽  
Record System ◽  
Care Facilities ◽  
Electronic Health

scholarly journals The effect of electronic reminders on the recording of diagnoses in primary care: A quasi-experimental before and after study

2020 ◽  
Vol 8 ◽  
pp. 205031212091826
Author(s):  
Tuomo Lehtovuori ◽  
Anna M Heikkinen ◽  
Marko Raina ◽  
Timo Kauppila
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Primary Health Care ◽  
Electronic Health Record ◽  
Health Record ◽  
Record System ◽  
Electronic Reminder ◽  
Primary Health ◽  
Before And After ◽  
Quasi Experimental

Objectives: This study examined whether using electronic reminders leads to an increase in the rate of diagnosis recordings in the electronic health record system following visits to a general practitioner. The impact of electronic reminders was studied in the primary health care of a Finnish city. Methods: This observational quasi-experimental study based on a before-and-after design was carried out by installing an electronic reminder to improve the recording of diagnoses in the computerized electronic health record system. The quantity of the recorded diagnoses was observed before and after the intervention. The effect of this intervention on the distribution of different diagnoses was also studied. Results: Before intervention, 33%–46% of visits (to general practitioners/month) had recorded diagnose in the primary health care units. After 4 years, the recording rate had risen to 87%–95% (p < 0.001). The rate of change in the recording of diagnoses was highest during the first year of intervention and plateaued about 3.5 years after application reminders. In the present study, most of the visits concerned mild respiratory infections, elevated blood pressure, low back pain and type 2 diabetes. Conclusion: An electronic reminder is likely to improve the recording of diagnoses during the visits to general practitioners. The distribution of diagnoses was in line with former reports concerning diagnoses in Finnish primary care.

scholarly journals Developing Clinical Decision Support within a Commercial Electronic Health Record System to Improve Antimicrobial Prescribing in the Neonatal ICU

2014 ◽  
Vol 05 (02) ◽  
pp. 368-387 ◽  
Author(s):  
K. Cato ◽  
B. Sheehan ◽  
S. Patel ◽  
J. Duchon ◽  
P. DeLaMora ◽  
...  
Keyword(s):  
Decision Support ◽  
Electronic Health Record ◽  
Clinical Decision Support ◽  
Clinical Decision ◽  
Electronic Health Record System ◽  
Health Record ◽  
Record System ◽  
Antimicrobial Prescribing ◽  
Neonatal Icu ◽  
Electronic Health

SummaryObjective: To develop and implement a clinical decision support (CDS) tool to improve antibiotic prescribing in neonatal intensive care units (NICUs) and to evaluate user acceptance of the CDS tool.Methods: Following sociotechnical analysis of NICU prescribing processes, a CDS tool for empiric and targeted antimicrobial therapy for healthcare-associated infections (HAIs) was developed and incorporated into a commercial electronic health record (EHR) in two NICUs. User logs were reviewed and NICU prescribers were surveyed for their perceptions of the CDS tool.Results: The CDS tool aggregated selected laboratory results, including culture results, to make treatment recommendations for common clinical scenarios. From July 2010 to May 2012, 1,303 CDS activations for 452 patients occurred representing 22% of patients prescribed antibiotics during this period. While NICU clinicians viewed two culture results per tool activation, prescribing recommendations were viewed during only 15% of activations. Most (63%) survey respondents were aware of the CDS tool, but fewer (37%) used it during their most recent NICU rotation. Respondents considered the most useful features to be summarized culture results (43%) and antibiotic recommendations (48%).Discussion: During the study period, the CDS tool functionality was hindered by EHR upgrades, implementation of a new laboratory information system, and changes to antimicrobial testing methodologies. Loss of functionality may have reduced viewing antibiotic recommendations. In contrast, viewing culture results was frequently performed, likely because this feature was perceived as useful and functionality was preserved.Conclusion: To improve CDS tool visibility and usefulness, we recommend early user and information technology team involvement which would facilitate use and mitigate implementation challenges.Citation: Hum RS, Cato K, Sheehan B, Patel S, Duchon J, DeLaMora P, Ferng YH, Graham P, Vawdrey DK, Perlman J, Larson E, Saiman L. Developing clinical decision support within a commercial electronic health record system to improve antimicrobial prescribing in the neonatal ICU. Appl Clin Inf 2014; 5: 368–387 http://dx.doi.org/10.4338/ACI-2013-09-RA-0069

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