Medical Documentation Issues and Hurdles

Dr. Sameer VankarSenior Resident

Emergency MedicineJPNATC,AIIMS,New Delhi

Medical Record Papers

• Disadvantages: Documentation issues Organizational issues-Storage & Retrieval Wear and Tear

Documentation issues

Storage

Wear & Tear

EMR

An electronic medical record (EMR) is a computerized

medical record created in an organization that delivers

care, such as a hospital

11

Patient’s entire health record

Cover Page Areas

Menu Bar

View or add current problems

Lab reports

Hospital visit data

METHODOLOGY

• Study design- Qualitative survey • Performance centre - ED of JPN Apex Trauma

Centre, AIIMS• Study duration-February to October 2010 (3 surveys)• Study Group-22 Emergency Care Providers

Doctors 8

Nurses 14

Total 22

Study Tool

Structured, closed ended questionnaire consisted of 12 questions based on:

Usability

Applicability

Security

Helpful in research of EMR

Question Are you aware of CPRS (computerized patient record system)? a) Yes b) No If your answer to the above question is ‘Yes’ please proceed below:

Usability: 1. Do you have problem in logging into CPRS? a) Never b) Sometimes c) Very often d) Always 2. Overall, how easy is the computerized MLC form? a) Not at all b) To some extent c) easy d) Very useful

3. Overall, how easy is the computerized transfer notes? a) Not at all b) To some extent c) easy d) Very easy

4. Overall, how easy is the computerized discharge summary? a) Not at all b) To some extent c) easy d) Very easy

5. Overall, how easy is the computerized entry of patient vitals? a) Not at all b) To some extent c) easy d) Very easy

Applicability:

6. Do you think this system is helpful in overall patient care? a) Never b) Sometimes c) Very often d) Always

7. Do you feel demographics are more accurately entered in all forms (MLC form, transfer out forms, discharge summary) by using the computerized system? a) Never b) Sometimes c) Very often d) Always

8. Do you think computerized MLC form is helpful for police and judiciary (courts)? a) Never b) Sometimes c) Very often d) Always

Security:

10. Do you think data can be manipulated in system (after sign off)? a) Never b) Sometimes c) Very often d) Always

11. Do you think this system will help in improving transparency and accountability? a) Never b) Sometimes c) Very often d) Always

Research: 12. Do you feel this system can be helpful in research? a) Never b) Sometimes c) Very often d) Always

METHODOLOGY (CONTD.)

• Likert scale (LS) was used (Likert 1=worst, likert 4=best)

• Surveys were done on day- 20 ,

day- 45 day and

9 months of implementation of EMR

• Response of emergency care providers (ECP) were compiled

• Data analyzed by SPSS version 16

Result

log

in p

robl

em

ease

of c

ompu

teriz

ed M

LC

ease

of e

lect

roni

c tra

nsfe

r not

es

elec

troni

c di

scha

rge

sum

mer

ies

vita

l ent

ry

help

ful i

n pa

tient

car

e

dem

ogra

phics a

ccur

acy

appl

icabi

lity

of e

lect

roni

c MLC

form

man

ipul

atio

n of

dat

a

trans

pare

ncy

and

acco

unta

bilit

y

rese

arch

0

0.5

1

1.5

2

2.5

3

3.5

4

2.23

2.5 2.45 2.41

2.71 2.72

32.82

1.41

2.77

3.32S1 S2 S3

Hurdles

Hurdles

Hurdles

Hurdles

Advantages

• Relatively complete• Tamper proof• Learning• Research• Easy retrieval