Quality of documentation of electronic medical information systems at primary health care units
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Abstract
There is limited data available on the implementation of electronic records systems in primary care, especially in developing countries. This study aimed to evaluate the quality of documentation in electronic medical records (EMRs) at primary healthcare units , and to gather physicians' feedback on the barriers and facilitators to the system's adoption. Data were gathered from 7 units randomly selected from each administrative region. In each unit, 50 paper-based records and their corresponding EMRs were randomly selected for patients who visited during the first three months . While administrative data were largely complete in both paper and electronic formats, the completeness of clinical data varied between 60.0% and 100.0% across different units and record types. The accuracy rate of the main diagnosis in EMRs compared to paper-based records ranged from 44.0% to 82.0%. High workload and system complexity emerged as the most frequently mentioned barriers to the successful implementation of EMRs
References
2. Tolar M, Balka E. Utilization of EMR Data in Primary Care: A Study in Health Technology and Informatics, 2011, 164:143–147.
3. Tomasi E, Facchini LA, Maia MF. Health information technology in primary health care in developing countries: a literature review. Bulletin of the World Health Organization, 2004, 82:867–874.
4. Pourasghar F et al. Challenges in Medical Records Management: Lessons from the Women's Hospital in Tabriz, Iran. BMC Public Health, 2008, 8:139. doi.org/10.1186/1471-2458-8-139.
5. Farhan J et al. Documentation and Coding Practices in a Tertiary Care Center: A Pilot Study. Annals of Saudi Medicine, 2005, 25:46–49.
6. Hippisley-Cox J et al. The electronic patient record in primary care—regression or progression? A cross-sectional study. British Medical Journal, 2003, 326:1439–1443.
7. Mikkelsen G, Aasly J. Concordance of information in parallel electronic and paper-based patient records. International Journal of Medical Informatics, 2001, 63:123–131.
8. Stengel D et al. Comparison of handheld computer-assisted and conventional paper chart documentation of medical records: A randomized, controlled trial. Journal of Bone and Joint Surgery, 2004, 86A:553–560.
9. Tsai J, Bond G. A comparison of electronic records to paper records in mental health centers. International Journal for Quality in Health Care, 2008, 20:136–143.
10. Sallam I. Healthcare Challenges in Egypt. Lancet, 1998, 352:1632.
11. Lie DA et al. An international physician education program to support family medicine introduction in Egypt. Family Medicine, 2004, 36:739–746.
12. Ward TR. Implementing a gatekeeper system to strengthen primary care in Egypt: a pilot study. Eastern Mediterranean Health Journal, 2010, 16:684–689.
13. Hahn KA et al. Electronic medical records and documentation in community primary care practices. American Journal of Medical Quality, 2011, 26:272–277.
14. Stausberg J et al. Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes. Journal of the American Medical Informatics Association, 2003, 10:470–477.
15. Pringle M, Ward P, Chilvers C. Assessment of the completeness and accuracy of computerized medical records in practices committed to computerized data recording. British Journal of General Practice, 1995, 45:537–541.
16. Logan JR, Gorman PN, Middleton B. Measuring the quality of medical records: a method for comparing completeness and correctness of clinical encounter data. Proceedings of AMIA Annual Symposium, 2001:408–412.
17. Miller RH, Sim I. Physicians’ use of electronic medical records: barriers and solutions. Health Affairs, 2004, 23:116–126.
18. Vishwanath A, Scamurra SD. Barriers to the adoption of electronic health records: developing a comprehensive empirical model. Health Informatics Journal, 2007, 13:119–134.
19. Laerum H, Ellingsen G, Faxvaag A. Doctors’ use of electronic medical records systems in hospitals: a cross-sectional survey. British Medical Journal, 2001, 323:1344–1348.
20. Jha AK et al. Electronic health records: use, barriers and satisfaction among physicians caring for minority patients. Journal of Evaluation in Clinical Practice, 2009, 15:158–163.
21. Meade B, Buckley D, Boland M. Factors affecting electronic patient records use by Irish GPs. International Journal of Medical Informatics, 2009, 78:551–558.
22. Terry AL et al. Key factors in implementing electronic health records in primary care. Canadian Family Physician, 2008, 54:730–736.
23. Boonstra A, Broekhuis M. Barriers to the acceptance of electronic medical records by physicians: a systematic review. BMC Health Services Research, 2010, 10:231. doi.org/10.1186/1472-6963-10-231.
24. Simon SR et al. Physicians and electronic health records: a statewide survey. Archives of Internal Medicine, 2007, 167:507–512.
25. El-Kareh R et al. Trends in primary care clinician perceptions of a new electronic health record. Journal of General Internal Medicine, 2009, 24:464–468.
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