International journal of medical informatics
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The goal of this study was to examine the effects of medical notes (MD) in an electronic medical records (EMR) system on doctors' work practices at an Emergency Department (ED). ⋯ We suggest three guidelines for designing future EMR systems to be used in teaching hospitals. First, the design of documentation tools in EMR needs to take into account what we called "note-intensive tasks" to support the collaborative nature of medical work. Second, it should clearly define roles and responsibilities. Lastly, the system should provide a balance between flexibility and interruption to better manage the complex nature of medical work and to facilitate necessary interactions among ED staff and patients in the work environment.
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Use of an anesthesia information management system (AIMS) does not insure record completeness and data accuracy. Mandatory data-entry fields can be used to assure data completeness. However, they are not suited for data that is mandatory depending on the clinical situation (context sensitive). For example, information on equal breath sounds should be mandatory with tracheal intubation, but not with mask ventilation. It was hypothesized that employing context-sensitive mandatory data-entry fields can insure high data-completeness and accuracy while maintaining usability. ⋯ Using context-sensitive mandatory fields in an anesthesia information management system was associated with high record completeness rate and data concordance. In addition, the system's usability was rated as very good by its users.
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Comparative Study
Structured electronic operative reporting: comparison with dictation in kidney cancer surgery.
The purpose of this study was to evaluate the functionality of eKidney as a structured reporting tool in operative note generation. To do this, we compared completeness and timeliness of eKidney template-generated nephrectomy OR notes with standard narrative dictation. ⋯ We have demonstrated that the use of structured reporting improves the completeness and timeliness of documentation in kidney cancer surgery. eKidney is an example of the power of templates in ensuring that important details of a procedure are recorded. Future studies looking at user satisfaction, and research and educational potential of eKidney would be valuable.
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This study examined the current prevalence of electronic health records (EHRs) in Korea and identified the factors that impede or facilitate the adoption of EHRs. ⋯ The rate at which EHR and CPOE for medications systems have been adopted by Korean tertiary teaching and general hospitals was higher than the rate of adoption by US hospitals. Financial aspects are reported to be the most important facilitators of and barriers to EHR adoption. Government financial support, especially to small hospitals, seems to be essential to promoting the adoption of EHRs by Korean hospitals.