The emergency medicine department system: a study of the effects of computerization on the quality of medical records

Computer-generated structured electronic medical records are preferable to conventional medical records for patients with acute abdominal pain - a prospective, double-blinded study

Objectives

Structured medical records improve readability and ensure the inclusion of information necessary for correct diagnosis and treatment. This is the first study to assess the quality of computer-generated structured medical records by comparing them to conventional medical records on patients with acute abdominal pain.

Materials and methods

A prospective double-blinded study was conducted in a tertiary referral center emergency department between January 2018 and June 2018. Patients were examined by emergency department physicians and by experience and inexperienced researcher. The researchers used a new electronical medical records system, which gathered data during the examination and the system generate structured medical records containing natural language. Conventional medical records dictated by physician and computer-generated medical records were compared by a group of independent clinicians.

Results

Ninety-nine patients were included. The overall quality of the computer-generated medical records was better than the quality of conventional human-generated medical records – the structure was similar or better in 99% of cases and the readability was similar or better in 86% of cases, p < 0.001. The quality of medical history, current illness, and findings of physical examinations were likewise better with the computer-generated recording. The results were similar when patients were examined by experienced or inexperienced researcher using the computer-generated recording.

Discussion

The quality of computer-generated structured medical records was superior to that of conventional medical records. The quality remained similar regardless of the researcher’s level of experience. The system allows automatic risk scoring and easy access for quality control of patient care. We therefore consider that it would be useful in wider practice.

Variables associated with completeness of medical record documentation in the emergency department

OBJECTIVE

The completeness of ED medical record documentation is often suboptimal. We aimed to determine the variables associated with documentation completeness in a large, tertiary referral ED.

METHODS

We audited 1200 randomly selected medical records of patients who presented with either abdominal pain, cardiac chest pain, shortness of breath or headache between May-July 2013 and May-July 2016. Data were collected on patient and treating doctor variables. Documentation completeness was assessed using a 0-10 point scoring tool designed for the study. A maximum score was achieved if each of 10 pre-determined important items, specific to the presenting complaint, were documented (five medical history items, five physical examination items). Data were analysed using multivariate regression.

RESULTS

The presenting year, day and time, patient age and gender, preferred language, interpreter requirement, discharge destination and doctor gender were not associated with documentation completeness (P > 0.05). Patients with triage category 3 or pain score of 6-7 had higher documentation scores (P < 0.05). Compared to interns, registrars (effect size -0.72, 95% CI -1.02 to -0.42, P < 0.01) and consultants (-1.62, 95% CI -1.95 to -1.29, P < 0.01) scored significantly less. The headache patient subgroup scored significantly less than the other patient subgroups (-0.35, 95% CI -0.63 to -0.08, P = 0.01). For all presenting complaint subgroups, examination findings were less well documented than history items (P < 0.001).

CONCLUSION

Documentation completeness is less among senior doctors, headache patients and for examination findings. Research should determine if the supervision responsibilities of senior doctors affects documentation and if medico-legal and patient care implications exist.

First medical contact and physicians' opinion after the implementation of an electronic record system

Hospitals implement electronic medical record systems (EMRSs) that are intended to support medical and nursing staff in their daily work. Evolution toward more computerization seems inescapable. Nevertheless, this evolution introduced new problems of organization. This before-and-after observational study evaluated the door-to-first-medical-contact (FMC) times before and after the introduction of EMRS. A satisfaction questionnaire, administered after the "after" period, measured clinicians' satisfaction concerning computerization in routine clinical use. The following 5 questions were asked: Do you spare time in your note taking with EMRS? Do you spare time in the medical care that you provide to the patients with EMRS? Does EMRS improve the quality of medical care for your patients? Are you satisfied with the EMRS implementation? Would you prefer a return to handwritten records? Results showed an increase in door-to-FMC time induced by EMRS and a lower triage capacity. In the satisfaction questionnaire, clinicians reported minimal satisfaction but refused to return to handwritten records. The increase in door-to-FMC time may be explained by the improved quantity/quality of data and by the many interruptions due to the software. Medical reorganization was requested after the installation of the EMRS.

Electronic interface for emergency department management of asthma: a randomized control trial of clinician performance

OBJECTIVES

To evaluate the effectiveness of an integrated and dynamic electronic decision support system for management of acute asthma in the ED.

METHODS

A randomized trial was conducted comparing clinician performance using this electronic interface compared with paper documentation in a simulation scenario. The outcomes were documentation of asthma-related information and consultation times.

RESULTS

Use of this electronic interface was associated with significantly higher rates of documentation in 7 out of 10 variables, including provision of written short-term asthma management plans. After adjustment for participant seniority, there was no significant difference in consultation times.

CONCLUSION

In a simulation trial, use of this electronic interface was associated with improvements in clinical and discharge documentation. Further studies are required to test this prototype in clinical practice.

Completeness of medical records in emergency trauma care and an IT-based strategy for improvement

The medical trauma record, produced in the Accident & Emergency Departments (AEDs) receives much attention from both health-care professionals and parties interested in quality of care. While it is an important data source for health-care professionals in their everyday work, and for quality assessment by third parties, the (paper) medical record is usually negatively evaluated because of incompleteness. In this article, we show that completeness is relative to the purpose for which the record is used. We distinguish two contexts in which the trauma record is used: the primary-care process at the AED, and assessment and monitoring of trauma care. Incompleteness of the medical record is valued differently in these contexts. Especially with regard to the information demands of quality assessment, and more specifically the national trauma registry, the work processes in the AED have not evolved sufficiently as yet. Information technology has great power to improve completeness and to facilitate quality assessment, but it cannot solve the problem of incompleteness in itself. One solution we propose is to restructure the recording process by introducing a clerk. This clerk could also be a nurse or physician who is temporarily released from direct patient care.

Information technology in emergency medicine residency-affiliated emergency departments

OBJECTIVES

To describe acquisition and implementation of information technology (IT) in U.S. emergency medicine (EM) residency-affiliated emergency departments (EDs), including automatic medication error checking.

METHODS

This was a survey of all U.S. EM residencies active in September 2000. Respondents specified whether specific IT tools had been "acquired" and "implemented fully." EDs were categorized according to primary versus affiliated training site, trauma level, and census. Numbers of "yes" responses were compared according to ED type (Kruskal-Wallis test, p < or = 0.05 significant).

RESULTS

Of 121 residency programs, data were obtained from 93 (77%) for a total of 149 EDs. The percentages of EDs that reported full implementation for each technology are as follows: medication error checking, 7%; medication order entry, 18%; nonmedication orders, 7%; clinical documentation, 21%; old electrocardiograms, 62%; laboratory results, 84%; radiography order entry, 62%; image retrieval, 29%; radiologists' interpretations, 67%; cardiology reports, 62%; pathology reports, 70%; surgical reports/dictations, 60%; triage, 34%; tracking, 46%; electronic reference materials, 56%; registration, 84%; accounts, 72%; patient management software package, 20%; voice recognition, 7%. Trauma centers reported more IT tools than nontrauma centers (p = 0.01), and primary training sites reported fewer IT tools than affiliated EDs (p = 0.027).

CONCLUSIONS

Incorporation of IT is not uniform in EDs where EM residents train. Acquisition of effective IT tools varies, and implementation lags behind acquisition. Fully implemented IT for medication error checking was reported in 7% of EDs; an additional 12% had acquired IT without implementing it fully.