Hostname: page-component-586b7cd67f-t7fkt Total loading time: 0 Render date: 2024-11-26T06:27:56.775Z Has data issue: false hasContentIssue false
  • English
  • Français

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

Published online by Cambridge University Press:  01 October 2008

Faramarz Pourasghar ,
Hossein Malekafzali ,
Sabine Koch  and
Uno Fors
Faramarz Pourasghar
Affiliation:
Karolinska Institutet and Tabriz University of Medical Sciences and National Public Health Management Center
Hossein Malekafzali
Affiliation:
Tehran University of Medical Sciences
Sabine Koch
Affiliation:
Karolinska Institutet
Uno Fors
Affiliation:
Karolinska Institutet
Get access Rights & Permissions [Opens in a new window]

Abstract

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.

Keywords

Electronic medical recordsPaper-based medical recordsDocumentation
Type
GENERAL ESSAYS
Information
International Journal of Technology Assessment in Health Care , Volume 24 , Issue 4 , October 2008 , pp. 445 - 451
Copyright
Copyright © Cambridge University Press 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1. Adams, WG, Mann, AM, Bauchner, H. Use of an electronic medical record improves the quality of urban pediatric primary care. Pediatrics. 2003;111:626–632.Google Scholar
2. Ammenwerth, E, Eichstädter, R, Haux, R et al., A randomized evaluation of a computer-based nursing documentation system. Methods Inf Med. 2001;40:61–68.Google Scholar
3. Barnett, GO, Jenders, RA, Chueh, HC. The computer-based clinical record–where do we stand? Ann Intern Med. 1993;119:1046–1048.CrossRefGoogle ScholarPubMed
4. Embi, PJ, Yackel, TR, Logan, JR, et al. Impacts of computerized physician documentation in a teaching hospital: Perceptions of faculty and resident physicians. JAMA. 2004;11:300–309.Google Scholar
5. Jolt, R, Renske, KL, Bleeker, SE, et al. Paper versus computer: Feasibility of an electronic medical record in general pediatrics. Am Acad Pediatr. 2006;117:15–21.Google Scholar
6. Lehmann, CU, Kim, GR, Lehmann, HP. Reducing the paper load: Computer-based patient records. Semin Pediatr Surg. 2000;9:19–23.Google Scholar
7. Merkouris, AV. Computer-based documentation and bedside terminals. J Nurs Manag. 1995;3:81–85.Google Scholar
8. Minda, S, Brundage, DJ. Time differences in handwritten and computer documentation of nursing assessment. Comput Nurs. 1994;12:277–279.Google ScholarPubMed
9. Ministry of Health and Medical Education of Iran. Medical record standard forms. 2002. Document 1290. Tehran: Ministry of Health and Medical Education.Google Scholar
10. Nygren, E, Wyatt, JC, Wright, P. Helping clinicians to find data and avoid delays. Lancet. 1998;352:1462–1466.Google Scholar
11. Pabst, MK, Scherubel, JC, Minnick, AF. The impact of computerized documentation on nurses' use of time. Comput Nurs. 1996;14:25–30.Google Scholar
12. Patterson, P. Computers and nurses. Nurs Prax N Z. 1992;7:21–24.Google ScholarPubMed
13. Pourasghar, F, Malekafzali, H, Kazemi, A, et al. What they fill in today, may not be useful tomorrow: Lessons learned from studying Medical Records at the Women hospital in Tabriz, Iran. BMC Public Health. 2008;8:139.Google Scholar
14. Rodriguez, NJ, Murillo, V, Borges, JA, Ortiz, J, Sands, DZ. A usability study of physicians' interaction with a paper-based patient record system and a graphical-based electronic patient record system. Proc AMIA Symp. 2002:667–671.Google Scholar
15. Saarinen, K, Aho, M. Does the implementation of a clinical information system decrease the time-intensive care nurses spend on documentation of care? Acta Anaesthesiol Scand. 2005;49:62–65.Google Scholar
16. WG, Williams, Morgan, JM. The clinician-information interface. Medinfo. 1995;8:801–805.Google Scholar