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

Abstract

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. | 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.