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Article: The application of a computerized problem-oriented medical record system and its impact on patient care

TitleThe application of a computerized problem-oriented medical record system and its impact on patient care
Authors
Issue Date1999
PublisherElsevier Ireland Ltd. The Journal's web site is located at http://www.elsevier.com/locate/ijmedinf
Citation
International Journal Of Medical Informatics, 1999, v. 55 n. 1, p. 47-59 How to Cite?
AbstractThe present computer system is the first of its kind based on problem- oriented medical record (POMR) design developed and operated in a hospital in Hong Kong. It went live in May 1996 with two workstations installed in the medical record office (MRO). Doctors have no direct access to it. They dictate medical notes on tape using either structured or free dictation format, and the tape is brought to the MRO for processing. The principal aim of this study is to study the impact of the computer system on patient care. Retrospective review of medical records and in-depth interviews were conducted to study the quality of medical records and doctor's opinions. A total of 400 manual and 398 computerized patient records were randomly selected for review. The completeness of the manual notes and computerized notes using free dictation format were about the same. The computerized records using structured dictation format may be more complete than those using free dictation format. The in-depth interview shows that most doctors preferred structured medical records but some disagreed with too detailed a level of structuring. They were not familiar with POMR, and some even thought that breaking down the record by problem was not possible. All felt that the present system would not directly affect patient care, but some said that it would facilitate research. In conclusion, since the utility of the information mainly depends on the doctors' efforts, commitment to the agreed structure and subsequent routine audit of computerized medical records are essential to make sure that diagnoses are accurately coded and information is correctly structured. | The present computer system is the first of its kind based on problem-oriented medical record (POMR) design developed and operated in a hospital in Hong Kong. It went live in May 1996 with two workstations installed in the medical record office (MRO). Doctors have no direct access to it. They dictate medical notes on tape using either structured or free dictation format, and the tape is brought to the MRO for processing. The principal aim of this study is to study the impact of the computer system on patient care. Retrospective review of medical records and in-depth interviews were conducted to study the quality of medical records and doctor's opinions. A total of 400 manual and 398 computerized patient records were randomly selected for review. The completeness of the manual notes and computerized notes using free dictation format were about the same. The computerized records using structured dictation format may be more complete than those using free dictation format. The in-depth interview shows that most doctors preferred structured medical records but some disagreed with too detailed a level of structuring. They were not familiar with POMR, and some even thought that breaking down the record by problem was not possible. All felt that the present system would not directly affect patient care, but some said that it would facilitate research. In conclusion, since the utility of the information mainly depends on the doctors' efforts, commitment to the agreed structure and subsequent routine audit of computerized medical records are essential to make sure that diagnoses are accurately coded and information is correctly structured.
Persistent Identifierhttp://hdl.handle.net/10722/86645
ISSN
2015 Impact Factor: 2.363
2015 SCImago Journal Rankings: 1.405
ISI Accession Number ID
References

 

DC FieldValueLanguage
dc.contributor.authorHo, LMen_HK
dc.contributor.authorMcGhee, SMen_HK
dc.contributor.authorHedley, AJen_HK
dc.contributor.authorLeong, JCYen_HK
dc.date.accessioned2010-09-06T09:19:34Z-
dc.date.available2010-09-06T09:19:34Z-
dc.date.issued1999en_HK
dc.identifier.citationInternational Journal Of Medical Informatics, 1999, v. 55 n. 1, p. 47-59en_HK
dc.identifier.issn1386-5056en_HK
dc.identifier.urihttp://hdl.handle.net/10722/86645-
dc.description.abstractThe present computer system is the first of its kind based on problem- oriented medical record (POMR) design developed and operated in a hospital in Hong Kong. It went live in May 1996 with two workstations installed in the medical record office (MRO). Doctors have no direct access to it. They dictate medical notes on tape using either structured or free dictation format, and the tape is brought to the MRO for processing. The principal aim of this study is to study the impact of the computer system on patient care. Retrospective review of medical records and in-depth interviews were conducted to study the quality of medical records and doctor's opinions. A total of 400 manual and 398 computerized patient records were randomly selected for review. The completeness of the manual notes and computerized notes using free dictation format were about the same. The computerized records using structured dictation format may be more complete than those using free dictation format. The in-depth interview shows that most doctors preferred structured medical records but some disagreed with too detailed a level of structuring. They were not familiar with POMR, and some even thought that breaking down the record by problem was not possible. All felt that the present system would not directly affect patient care, but some said that it would facilitate research. In conclusion, since the utility of the information mainly depends on the doctors' efforts, commitment to the agreed structure and subsequent routine audit of computerized medical records are essential to make sure that diagnoses are accurately coded and information is correctly structured. | The present computer system is the first of its kind based on problem-oriented medical record (POMR) design developed and operated in a hospital in Hong Kong. It went live in May 1996 with two workstations installed in the medical record office (MRO). Doctors have no direct access to it. They dictate medical notes on tape using either structured or free dictation format, and the tape is brought to the MRO for processing. The principal aim of this study is to study the impact of the computer system on patient care. Retrospective review of medical records and in-depth interviews were conducted to study the quality of medical records and doctor's opinions. A total of 400 manual and 398 computerized patient records were randomly selected for review. The completeness of the manual notes and computerized notes using free dictation format were about the same. The computerized records using structured dictation format may be more complete than those using free dictation format. The in-depth interview shows that most doctors preferred structured medical records but some disagreed with too detailed a level of structuring. They were not familiar with POMR, and some even thought that breaking down the record by problem was not possible. All felt that the present system would not directly affect patient care, but some said that it would facilitate research. In conclusion, since the utility of the information mainly depends on the doctors' efforts, commitment to the agreed structure and subsequent routine audit of computerized medical records are essential to make sure that diagnoses are accurately coded and information is correctly structured.en_HK
dc.languageengen_HK
dc.publisherElsevier Ireland Ltd. The Journal's web site is located at http://www.elsevier.com/locate/ijmedinfen_HK
dc.relation.ispartofInternational Journal of Medical Informaticsen_HK
dc.rightsInternational Journal of Medical Informatics. Copyright © Elsevier Ireland Ltd.en_HK
dc.subject.meshAttitude of Health Personnelen_HK
dc.subject.meshAttitude to Computersen_HK
dc.subject.meshComputer Systemsen_HK
dc.subject.meshEvaluation Studies as Topicen_HK
dc.subject.meshHong Kongen_HK
dc.subject.meshHospitals, Specialen_HK
dc.subject.meshHumansen_HK
dc.subject.meshMedical Records Systems, Computerized - standardsen_HK
dc.subject.meshMedical Records, Problem-Orienteden_HK
dc.subject.meshPatient Careen_HK
dc.subject.meshPhysiciansen_HK
dc.subject.meshWorkloaden_HK
dc.titleThe application of a computerized problem-oriented medical record system and its impact on patient careen_HK
dc.typeArticleen_HK
dc.identifier.openurlhttp://library.hku.hk:4550/resserv?sid=HKU:IR&issn=1386-5056&volume=55&spage=47&epage=59&date=1999&atitle=The+application+of+a+computerized+problem-oriented+medical+record+system+and+its+impact+on+patient+careen_HK
dc.identifier.emailHo, LM:lmho@hkucc.hku.hken_HK
dc.identifier.emailMcGhee, SM:smmcghee@hkucc.hku.hken_HK
dc.identifier.emailHedley, AJ:hrmrajh@hkucc.hku.hken_HK
dc.identifier.authorityHo, LM=rp00360en_HK
dc.identifier.authorityMcGhee, SM=rp00393en_HK
dc.identifier.authorityHedley, AJ=rp00357en_HK
dc.description.naturelink_to_subscribed_fulltext-
dc.identifier.doi10.1016/S1386-5056(99)00019-2en_HK
dc.identifier.pmid10471240-
dc.identifier.scopuseid_2-s2.0-0032765543en_HK
dc.identifier.hkuros41555en_HK
dc.relation.referenceshttp://www.scopus.com/mlt/select.url?eid=2-s2.0-0032765543&selection=ref&src=s&origin=recordpageen_HK
dc.identifier.volume55en_HK
dc.identifier.issue1en_HK
dc.identifier.spage47en_HK
dc.identifier.epage59en_HK
dc.identifier.isiWOS:000081762200006-
dc.publisher.placeIrelanden_HK
dc.identifier.scopusauthoridHo, LM=7402955625en_HK
dc.identifier.scopusauthoridMcGhee, SM=7003288588en_HK
dc.identifier.scopusauthoridHedley, AJ=7102584095en_HK
dc.identifier.scopusauthoridLeong, JCY=35564692000en_HK

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