Acceptance model of electronic medical record

This paper discusses acceptance issues of Electronic Medical Record System (EMR), particularly in Malaysia. A detailed overview of EMR and its benefits are firstly discussed. A number of acceptance models are scrutinized. Then factors affecting EMR acceptance are put forward. Finally, before proposing an EMR acceptance model, an instrument formed by adapting and then finding its factors loading is presented

Patient privacy protection using anonymous access control techniques

Objective: The objective of this study is to develop a solution to preserve security and privacy in a healthcare environment where health-sensitive information will be accessed by many parties and stored in various distributed databases. The solution should maintain anonymous medical records and it should be able to link anonymous medical information in distributed databases into a single patient medical record with the patient identity. Methods: In this paper we present a protocol that can be used to authenticate and authorize patients to healthcare services without providing the patient identification. Healthcare service can identify the patient using separate temporary identities in each identification session and medical records are linked to these temporary identities. Temporary identities can be used to enable record linkage and reverse track real patient identity in critical medical situations. Results: The proposed protocol provides main security and privacy services such as user anonymity, message privacy, message confidentiality, user authentication, user authorization and message replay attacks. The medical environment validates the patient at the healthcare service as a real and registered patient for the medical services. Using the proposed protocol, the patient anonymous medical records at different healthcare services can be linked into one single report and it is possible to securely reverse track anonymous patient into the real identity. Conclusion: The protocol protects the patient privacy with a secure anonymous authentication to healthcare services and medical record registries according to the European and the UK legislations, where the patient real identity is not disclosed with the distributed patient medical records

Malpractice and patient safety descriptors: an innovative grid to evaluate the quality of clinical records

Introduction: The medical record contains all the health information related to the patient’s clinical condition and its evolution during hospitalization. It was defined by the Italian Ministry of Health in 1992 as "The information tool designed to record all relevant demographic and clinical information about a patient during a single episode of hospitalization". The documents and information in a Medical Record must meet the following criteria: traceability, clarity, accuracy, authenticity, pertinence and completeness. The objectives of our study was to develop a tool capable of assessing the quality of the clinical record and pointed the critical point at the Organizational, Technical - Professional, Managerial level. Methods: To evaluate the quality of the medical documentation, we created an assessment grid composed of 4 sections with a total of 92 criteria. This grid was tested on 200 medical records that were randomly selected from 25 (18 medical and 7 surgical) wards of a teaching hospital in Rome. Results: The grid contains 4 sections. The first part regards administrative and clinical data; the second assesses the quality of hospital stay and surgical/invasive procedures; the third part is concerned with the discharge of the patient and the fourth aims to identify the presence of advisory reports given to the patient. This grid has been validated to verify internal consistency with Cronbach's Alpha = 0,743. Conclusions: Medical records were analyzed using a validated tool with grids to identify critical issues in care activities. Weaknesses in the system were identified in order to improve planning. The sample testing also in terms of ‘self-assessment' represents a tool to introduce activities to improve safety and quality of care, greatly reducing the costs of litigation

Integrated care and the working record

By default, many discussions and specifications of electronic health records or integrated care records often conceptualize the record as a passive information repository. This article presents data from a case study of work in a medical unit in a major metropolitan hospital. It shows how the clinicians tailored, re-presented and augmented clinical information to support their own roles in the delivery of care for individual patients. This is referred to as the working record: a set of complexly interrelated clinician-centred documents that are locally evolved, maintained and used to support delivery of care in conjunction with the more patient-centred chart that will be stored in the medical records department on the patient’s discharge. Implications are drawn for how an integrated care record could support the local tailorability and flexibility that underpin this working record and hence underpin practice

ELECTRONIC MEDICAL RECORD, A MEDICAL SERVICE CHALLENGE IN 4.0 ERA AND ITS LEGAL ASPECT

Background: All people need health services. As a concequences of that, we found great number of patients queue in public healh services. To reduce the patients queue, technology implemented. Electronic medical record is one of technology aplication that able to solve the problem of queueing. Indonesia has no special regulation on electronic medical record. Considering that background, author try to explore problems in implementation of electronic medical record, 1) is the electronic medical record valid as an evidence in litigation process (ethics and law) and 2) is electronic medical record able to provide information needed in patient management. Objective: Justification proofing of ethicolegal judgement in technology implementation of medical record documentation. Methods: This research uses mixed methods design: Quantitative method leading to in-depth ethically reflective method after coherent qualitative result. Populations of the research are outpatients, and the subject of this research are health workers of hospital that use electronic medical record. Results: Electronic medical record used is “computerized” or “automated” medical record. There are some paperless documents, combining with conventional record in implementation. There is significant difference on accessability and completeness between electronic medical record and conventional medical record. Electronic medical record able to improve the service quality, in beneficence and non-maleficence principle. There is no significant difference on legal quality between electronic medical record and conventional medical record. Implementation of automated medical record is an inter phase, before a hospital successfully implement fully electronic medical record. Conclusion: Automated medical record able to improove quality of medical record, based on beneficence and non-maleficence ethics principle. It’s needed further investigation to conclude autonomy and justice principle nowadays

Parent Perceptions of Infant Symptoms at End-of-Life in the NICU

Purpose and Significance: Despite significant technological advances, many infants admitted to the neonatal intensive care unit (NICU) do not survive. Limited research has focused on symptoms infants may experience as they approach end-of-life. The purpose of this study was to examine concordance in infant symptom identification between medical record and parental report. Conceptual Framework: The Framework for a Good Neonatal Death was used to guide this study. This framework includes the interaction of three domains: infant, parents, and nurses that may result in an improved experience at end-of-life. Symptom identification and parent perceptions are important concepts included within these domains. Method: 433 parents (248 mothers, 185 fathers) of infants who died in the NICU between 2009 and 2014 were invited to participate. Following informed consent, parents of 40 infants [40 mothers (M age = 33 years), 27 fathers (M age = 37 years)] reported on the presence of symptoms during the last week of their infant’s life. Medical record reviews were also completed for each infant. Parent survey and chart data were compared for six symptoms for which there was overlapping data: pain, agitation, respiratory distress, feeding intolerance, seizures, and lethargy. Results: Parents identified several symptoms (Mother M =2.8, Father M = 2.6, range = 1-5) with pain, agitation, and respiratory distress most commonly endorsed. Within the 27 parental dyads, mothers reported agitation significantly more than fathers, while fathers reported seizures significantly more than mothers. Comparisons between the medical record and parental report of symptoms demonstrated that both parents reported seizures more often than documented in the medical record. Parents reported frequencies similar to the chart for the presence of pain, agitation, respiratory distress, feeding intolerance, and lethargy. Conclusions: Parents demonstrate awareness of the infant’s well-being at end-of-life which closely matches medical staff documentation, however perceptions may differ between parents. Parent perceptions of infant symptom burden likely plays an important role in decision-making regarding treatment. Future research is needed to further understand parents’ views of symptom management and potential suffering as it relates to end-of-life care.The Clinical and Translational Research Intramural Funding Program at Nationwide Children's HospitalA three-year embargo was granted for this item.Academic Major: Nursin

Quality assessment of medical record as a tool for clinical risk management: a three year experience of a teaching hospital Policlinico Umberto I, Rome

Introduction: The medical record was defined by the Italian Ministry of Health in 1992 as "the information tool designed to record all relevant demographic and clinical information on a patient during a single hospitalization episode". Retrospective analysis of medical records is a tool for selecting direct and indirect indicators of critical issues (organizational, management and technical). The project’s aim being the promotion of an evaluation and self-evaluation process of medical records as a Clinical Risk Management tool to improve the quality of care within hospitals. Methods: The Authors have retrospectively analysed, using a validated grid, 1,184 medical records of patients admitted to the Teaching Hospital “Umberto I” in Rome during a three-year period (2013-2015). Statistical analysis was performed using SPSS for Windows © 19:00. All duly filled out criteria (92) were examined. “Strengths” and "Weaknesses" were identified through data analysis and Best and Bad Practice were identified based on established criteria. Conclusion: The data analysis showed marked improvements (statistically significant) in the quality of evaluated clinical documentation and indirectly upon behaviour. However, when examining some sub-criteria, critical issues emerge; these could be subject to future further corrective action

A systematic review of quality components of patients’ medical record in Iranian Hospital

Background: Quality of patients’ medical records is important in patient management, safety, decision making and continuation of care. Patients’ medical record data are also used in clinical research, health system services and management, medical forensic management, quality improvement, health care financial management, and risk management. Objective: The aims of the study were to determine the quality of the components of hospital patients’ medical records. Methods: The criteria selected for systematic searching were published articles in English from 1995 to 2014 for patient medical record quality components. The search terms were hospital patient medical record, reliability, accuracy, completeness, availability and accessibility. The study was carried out from 2013 to 2014 using public domain databases which include PubMed, Cochrane and CINHAL. Results: Over 2600 citations from the databases were extracted. Based on the criteria of the study 344 articles were selected for review. Subsequently, 7 articles were selected for reliability, 11 for accuracy, 18 for completeness and 9 for availability and accessibility. These articles were subjected to an in-depth review. Reliability of data in patients’ medical record is a requisite for accuracy and completeness of clinical data. The reliability scores of the studies reviewed ranged from 49% to 99%, while accuracy of patients’ medical record ranged from 73% to 95%. The reviewed studies also showed completeness of patients’ medical record ranging from 41.5% to 93%, while availability and accessibility scores ranged from 58% to 94.3%. Conclusion: This review had contributed to a better understanding of the quality of patients’ medical record. Reliability, accuracy, completeness and accessibility of patient medical record showed a wide range of quality of patients’ medical record. Good quality of patients’ medical record is essential for patient care and through preventing medical error. This review also revealed the importance of intervention to improve quality of patient medical record