Improvement of patient safety through implementation of electronic medical records

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care

Factors Associated with Completeness and Accuracy of Electronic Medical Record Entry in Community Health Center in Yogyakarta

Background: The implementation of electronic patient records in primary care is a key objective of many health care systems, including Indonesia. This reflects a growing recognition of the potential benefits of electronic records on the safety, quality and efficiency of healthcare. Documentation in the medical record is expected to be complete, accurate, concise, and timed/dated. This study aimed to analyze factors associated with completeness and accuracy of electronic medical record entry in community health center in Yogyakarta. Subjects and Method: This was an analytic observational study with a cross sectional design. The study was conducted in 25 community health centers in Yogyakarta, from March to June 2018. A sample of 200 patient medical records was selected by simple random sampling. The dependent variables were completeness and accuracy of medical record. The independent variables were tenure, multi task, and accreditation status of puskesmas. The data were collected by questionnaire and analyzed by a multiple logistic regression. Results: Completeness of electronic medical record was positively associated with longer tenure (b= 0.58; 95% CI= 0.10 to 1.05; p=0.018), but negatively associated with multiple task occupation (b= -2.12; 95% CI= -3.44 to -0.81; p= 0.002). Accuracy of electronic medical record was positively associated with longer tenure (b= 1.10; 95% CI= 0.34 to 1.85; p= 0.005), but negatively associated with multiple task occupation (b= -4.20; 95% CI= -6.30 to -2.11; p<0.001). Accreditation status of puskesmas did not affect completeness and accuracy. Conclusion: Completeness and accuracy of electronic medical record are positively associated with longer tenure, but negatively associated with multiple task occupation. Accreditation status of puskesmas does not affect completeness and accuracy. Keywords: electronic medical record, completeness, accuracy, tenure, occupation, community health cente

Annotation analysis for testing drug safety signals using unstructured clinical notes

BackgroundThe electronic surveillance for adverse drug events is largely based upon the analysis of coded data from reporting systems. Yet, the vast majority of electronic health data lies embedded within the free text of clinical notes and is not gathered into centralized repositories. With the increasing access to large volumes of electronic medical data-in particular the clinical notes-it may be possible to computationally encode and to test drug safety signals in an active manner.ResultsWe describe the application of simple annotation tools on clinical text and the mining of the resulting annotations to compute the risk of getting a myocardial infarction for patients with rheumatoid arthritis that take Vioxx. Our analysis clearly reveals elevated risks for myocardial infarction in rheumatoid arthritis patients taking Vioxx (odds ratio 2.06) before 2005.ConclusionsOur results show that it is possible to apply annotation analysis methods for testing hypotheses about drug safety using electronic medical records

Analysis Of Application Of The UTAUT Model On Behavior Of Use Of Electronic Medical Records In RSUD Prof Dr Margono Soekarjo Purwokerto

Medical records are an important tool for documenting patients‘ progress. The use ofelectronicmedical records is an effort to effectively manage patient condition data,support diagnosis andtherapy decisions and improve patient safety. Prof. Dr.Margono Soekarjo Purwokerto GeneralHospitalis a hospital that has implemented an electronic medicalrecord system. One of the modelsthat can assess the acceptance of an electronic system isUnified Theory of Acceptance and Use ofTechnology (UTAUT). UTAUT combines thesuccessful features of eight theories of technologyacceptance. UTAUT consists of 4constructs, namelyperformance expectancy (PE) effort expectancy(EE) social influence (SE)and facilitating conditions(FC). This study aims to determine thebehavior of doctors' use ofthe application of electronic medical records as a supporter of patientdevelopmentdocumentation at Margono Soekarjo General Hospital, Purwokerto.This research is aquantitativeresearchwith a cross sectional research design. Technique samplingused is randomsampling with the slovin formula obtained 49 respondents. Data collection by usingaquestionnaire. Data analysis in this study used the SEM-PLS analysis technique. The resultsof thisstudy prove that all UTAUT variables affect usage behavior with an R2 PE value of22.68%; EE45.61%; SI 7.03%; and FC23.3%, with a total R2 value of 88.61%. The GoF value is 0.5777, so itcan be concluded that theconstruct in the UTAUT model has an influence of 88.61% on thebehavior of using electronicmedical records in Prof. Dr. Margono Soekarjo General Hospital,Purwokerto.Keywords: Electronic Medical Record, UTAUT, Performance Expectancy (PE), EffortExpectancy(EE), Social Influence (SI) and Facilitating Condition (FC), Usage Behavior (UB

Medical Errors In U.S. Healthcare Organizations: Have We Made Any Progress?

Since the Institute of Medicine’s landmark 1999 report on medical errors, mandates, legislation, and recommendations have been forced on the U.S. healthcare industry. However, only limited progress has been made. Part of the difficulty is identifying the scope of the problem, which has been far larger than thought since the advent of new reporting tools. The major causes of medical errors lie in the lack of a (a) pervasive safety culture, (b) commitment by top healthcare organization management to reduce medical errors, and (c) integrated IT systems, including electronic health records. Compared to other “high reliability” organizations that have achieved excellent results in regard to safety, healthcare is perceived as lagging far behind. Healthcare is not the sole industry needing a safety culture. However, many healthcare leaders perceive existing industry tools that high reliability organizations routinely use as irrelevant. Positive change will come when attitudes change and healthcare organizations embrace the solutions that other industrial organizations have utilized to produce satisfactory safety outcomes.

The Coming Age Of Electronic Medical Records: From Paper To Electronic

Medical records, first developed in the fifth century, have remained virtually unchanged until the explosion of new technology in the mid-1960’s. The National Space and Aeronautics Administration’s development of computerized patient record (CPR) brought life to the electronic medical record (EMR) industry. Preventable deaths due to medical errors drew the attention of public and health care professionals to the need for increased patient safety and improved quality measures in medicine. With health care costs compromising 16-17% of the U.S. Gross Domestic Product, Congress passed legislation to financially support providers to adopt electronic medical record (EMR). As a result, future efforts will focus on the sharing of information among all health care stakeholders. Across the world, governments, technology companies, and care providers are collaborating efforts to make the EMR a reality

Integrating Safety Assessment into the Design of Healthcare Service-Oriented Architectures

Most healthcare organisations are service-oriented, fundamentally centred on critical services provided by medical and nursing staff. Increasingly, these human-centric services rely on software-intensive systems, i.e. medical devices and health informatics, for improving different aspects of healthcare, e.g. enhancing efficiency through automation and patient safety through smart alarm systems. However, many healthcare services are categorised as high risk and as such it is vital to analyse the ways in which the software-based systems can contribute to unintentional harm and potentially compromise patient safety. This paper proposes an approach to modelling and analysing Service-Oriented Architectures (SOAs) used in healthcare, with emphasis on identifying and classifying potential hazardous behaviour. The paper also considers how the safety case for these SOAs can be developed in a modular manner. The approach is illustrated through a case study based on three services: ambulance, electronic health records and childbirth services

Information technology in pharmacovigilance: Benefits, challenges, and future directions from industry perspectives

Risk assessment during clinical product development needs to be conducted in a thorough and rigorous manner. However, it is impossible to identify all safety concerns during controlled clinical trials. Once a product is marketed, there is generally a large increase in the number of patients exposed, including those with comorbid conditions and those being treated with concomitant medications. Therefore, postmarketing safety data collection and clinical risk assessment based on observational data are critical for evaluating and characterizing a product’s risk profile and for making informed decisions on risk minimization. Information science promises to deliver effective e-clinical or e-health solutions to realize several core benefits: time savings, high quality, cost reductions, and increased efficiencies with safer and more efficacious medicines. The development and use of standard-based pharmacovigilance system with integration connection to electronic medical records, electronic health records, and clinical data management system holds promise as a tool for enabling early drug safety detections, data mining, results interpretation, assisting in safety decision making, and clinical collaborations among clinical partners or different functional groups. The availability of a publicly accessible global safety database updated on a frequent basis would further enhance detection and communication about safety issues. Due to recent high-profile drug safety problems, the pharmaceutical industry is faced with greater regulatory enforcement and increased accountability demands for the protection and welfare of patients. This changing climate requires biopharmaceutical companies to take a more proactive approach in dealing with drug safety and pharmacovigilance

Improving the Quality of Clinical Coding through Mapping of National Classification of Diseases (NCoD) and International Classification of Disease (ICD-10).

AbstractIntroduction: Medical coding is the transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. Utilization of international disease classification provides higher-quality information for measuring healthcare service quality, safety, and efficacy. The Ethiopian National classification of disease (NCoD) was developed as part of Health Management information System (HMIS) reform with consideration of accommodating code in International Classification of disease (ICD-10). There is limited resource about the utilization status and related determinants of NCoD by health care professionals at tertiary level hospitals. This study is designed to assess the utilization status of NCoD and improve the quality of clinical coding through mapping of NCoD and ICD-10. Methods: Quasi-experimental study considering “Mapping” as an intervention was employed in this study. Retrospective medical record reviews were carried out to assess the utilization of NCoD and its challenges at Tikur Anebsa Specialized Hospital (TASH) for a period of one year (2018/2019). Qualitative approach used to get expert insight on NCoD implementation challenges and design of mapping exercises as an intervention. Seven thousand five hundred forty-seven (20%) of the medical records from the total of 37,734 medical records were selected randomly for review. A data abstraction checklist was developed to collect relevant information on individual patient charts, patient electronic records specific on a confirmed diagnosis. The reference mapping approach was employed for the mapping output between ICD-10 and NCoD. Both ICD-10 and NCoD were mapped side by side using percentage comparison and absolute difference. Result: Data for document review was taken from the electronic medical record database. Out of the total, 3021 (40%) of records were miss-classified based on the national classification of disease. From the miss-coded record, 1749 (58%) of them used ICD code to classify the diagnosis. Reasons provided for poor utilization of NCoD among physicians include, perception of having a limited list of diagnosis in the NCoD, not being familiarized, inadequate capacity building about NCoD use, and absence of enforcing mechanism on the use of standard diagnostic coding among professionals. Utilization of disease classification coding provides higher-quality information for measuring healthcare service quality, safety, and efficacy. This will in turn provide better data for quality measurement and medical error reduction (patient safety), outcomes measurement, operational planning, and healthcare delivery systems design and reporting. Conclusion: Extended NCoD categories were mapped from ICD-10. Standard ways of coding disease diagnosis and coding of new cases into the existing category was established. This study recommends that due emphasis should be given in monitoring and evaluation of medical coding knowledge and adherence of health professionals, and it should be supported with appropriate technologies to improve the accessibility and quality of health information. [Ethiop. J. Health Dev. 2021; 35(SI-1):59-65] Keywords: Mapping, NCoD, ICD, Clinical Coding, Diagnosis, Health Information Syste