Concordance of information in parallel electronic and paper based patient records

Mikkelsen, Gustav; Aasly, Jan

doi:10.1016/s1386-5056(01)00152-6

Cited by 75 publications

(44 citation statements)

References 11 publications

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“…In Germany, the introduction of a hand-held computer was associated with improved patient assessment, coding and number of recorded diagnoses [8], while in the United States of America (USA) e-records were 40% more complete and 20% faster to retrieve than paper-based records [9]. In contrast with the previous results, 4%-13% of the documents in the electronic record were found to be missing compared with 1% missing from paper records in a Norwegian university hospital [7].…”

Section: Introductionmentioning

confidence: 86%

“…Some authors, however, have warned that inadequate computer skills or lack of training of health professionals together with limitations in erecords software could result in the data in e-records being truncated compared with paper-based records [6]. Others have raised the concern that parallel use of paper-based and e-records could result in inconsistencies between the systems, caused by failure to update both versions of the record [7]. The results of studies performed to compare the quality and completeness of documentation in paper-based and erecords have been contradictory.…”

Section: Introductionmentioning

confidence: 99%

“…The results of studies performed to compare the quality and completeness of documentation in paper-based and erecords have been contradictory. While some studies revealed that data recording in e-records compared favourably with paper-based records, others have demonstrated that e-records sacrificed the thoroughness of data recording that is inherent in paper-based records [7,8]. In the United Kingdom (UK), e-records scored favourably when compared to paper-records with respect to legibility, comprehensibility and completeness [6].…”

Section: Introductionmentioning

confidence: 99%

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Quality of documentation of electronic medical information systems at primary health care units in Alexandria, Egypt

Noureldin

Mosallam

Salah³

2014

East Mediterr Health J

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Limited data are available about the implementation of electronic records systems in primary care in developing countries. The present study aimed to assess the quality of documentation in the electronic medical records at primary health care units in Alexandria, Egypt and to elicit physician's feedback on barriers and facilitators to the system. Data were collected at 7 units selected randomly from each administrative region and in each unit 50 paper-based records and their corresponding e-records were randomly selected for patients who visited the unit in the first 3 months of 2011. Administrative data were almost complete in both paper and e-records, but the completeness of clinical data varied between 60.0% and 100.0% across different units and types of record. The accuracy rate of the main diagnosis in e-records compared with paper-based records ranged between 44.0% and 82.0%. High workload and system complexity were the most frequently mentioned barriers to implementation of the e-records system. RÉSUMÉ Les données disponibles sur la mise en oeuvre de systèmes de dossiers électroniques en soins de santé primaires dans les pays en développement sont limitées. La présente étude visait à évaluer la qualité de la documentation des dossiers médicaux électroniques dans des unités de soins de santé primaires à Alexandrie (Égypte) et à recueillir les commentaires des médecins sur les obstacles et les leviers ayant un impact sur le système. Des données ont été recueillies au sein de sept unités sélectionnées aléatoirement dans chaque région administrative ; puis dans chaque unité, 50 dossiers au format papier et leurs dossiers électroniques correspondants ont été sélectionnés aléatoirement pour les patients qui avaient consulté dans l'unité de soins au cours de trois premiers mois de l'année 2011. Les données administratives étaient presque complètes dans les dossiers au format papier et au format électronique, mais l'exhaustivité des données cliniques variait entre 60 % et 100 % en fonction des unités de soins et du type de dossiers. Le taux d'exactitude du diagnostic principal dans les dossiers électroniques par rapport aux dossiers papiers était compris entre 44,0 % et 82,0 %. Une lourde charge de travail et la complexité du système étaient les obstacles les plus fréquemment cités à la mise en oeuvre du système de dossiers électroniques.

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Section: Introductionmentioning

confidence: 86%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Quality of documentation of electronic medical information systems at primary health care units in Alexandria, Egypt

Noureldin

Mosallam

Salah³

2014

East Mediterr Health J

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“…The Integrated System of Electronic Protocols (SINPE © ) 22 was developed to aim at the solution of some typical deficiencies found in researches, such as lack of terms standard; data of research that were not used in any other one; difficulties in making multicentric and multidisciplinary 19 research. It allows automatic, instantaneous and fast information.…”

Section: Introductionmentioning

confidence: 99%

Criação de protocolo eletrônico para terapia nutricional enteral domiciliar

Schieferdecker¹,

Kuretzki²,

Campos³

et al. 2013

ABCD, arq. bras. cir. dig.

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-Background: Informatics can help the development of home enteral nutrition therapy (HENT). By using an electronic protocol with an electronic database it is possible to organize, structure and manage, information. Aim: To develop an electronic protocol for data collection on treatment of patients with home enteral nutrition. Method: After a review in theoretical material about home enteral nutrition therapy, 1793 data collection items were selected and grouped into nine categories: patient identification, nutritional assessment, dietetics prescription, indications for enteral nutrition, access to enteral nutrition options, composition of enteral nutrition, administration system, complications, and readmission. Was used the Electronic Integrated Computerized Procotols System (SINPE © ) to organize that knowledge and the database that attends this research was named Informatized Master Protocol of HENT. The last step was the creation of a specific protocol to collect data by using informations from this database. Results: After installing the program, the system recognizes the user by identifying a pre-defined security authorization and also provides a screen to select a master protocol which the user can access. Items that arrange the specific protocol are contained in the Master Protocol and the information for this protocol are displayed. Conclusion: It was possible to create an electronic protocol for HENT patients care with safety data based on research in enteral nutrition support. RESUMO -

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“…'Language concordance' is the use and understanding of the same language [9]. In all these and other cases [10][11][12] the correspondence is perfect. However, clinicians' views about therapy can never be perfectly concordant with those of patients.…”

mentioning

confidence: 99%