Determining the requirements of a medical records electronic deficiency management system: a mixed-method study
ISSN: 0956-5698
Article publication date: 25 November 2022
Issue publication date: 30 November 2022
Abstract
Purpose
Despite the presence of electronic medical records systems, traditional paper-based methods are often used in many countries to document data and eliminate medical record deficiencies. These methods waste patient and hospital resources. The purpose of this study is to evaluate the traditional deficiency management system and determine the requirements of an electronic deficiency management system in settings that currently use paper records alongside electronic hospital information systems.
Design/methodology/approach
This mixed-method study was performed in three phases. First, the traditional process of medical records deficiency management was qualitatively evaluated. Second, the accuracy of identifying deficiencies by the traditional and redesigned checklists was compared. Third, the requirements for an electronic deficiency management system were discussed in focus group sessions.
Findings
Problems in the traditional system include inadequate guidelines, incomplete procedures for evaluating sheets and subsequent delays in activities. Problems also included the omission of some vital data elements and a lack of feedback about the documentation deficiencies of each documenter. There was a significant difference between the mean number of deficiencies identified by traditional and redesigned checklists (p < 0.0001). The authors proposed an electronic deficiency management system based on redesigned checklists with improved functionalities such as discriminating deficiencies based on the documenter’s role, providing systematic feedback and generating automatic reports.
Originality/value
Previous studies only examined the positive effect of audit and feedback methods to enhance the documentation of data elements in electronic and paper medical records. The authors propose an electronic deficiency management system for medical records to solve those problems. Health-care policymakers, hospital managers and health information systems developers can use the proposed system to manage deficiencies and improve medical records documentation.
Keywords
Acknowledgements
The authors would like to express gratitude to the staff of the medical records department of hospitals who participated in this study.
Funding: This work was supported by the Student Research Committee, Kerman University of Medical Sciences, Kerman, Iran [No. 97000447].
Author contributions: F. Salmanizadeh, A. Ameri, L. Ahmadian, M. Mirmohammadi and Reza Khajouei contributed to the conception and design of the study, acquisition and interpretation of the data and drafting the paper. All five authors read and approved the final version of the manuscript submitted.
Conflict of interest: The authors declare that there is no conflict of interest regarding the publication of this article.
Consent to participate: Informed consent was obtained from each participant prior to participation in this research.
Citation
Salmanizadeh, F., Ameri, A., Ahmadian, L., Mirmohammadi, M. and Khajouei, R. (2022), "Determining the requirements of a medical records electronic deficiency management system: a mixed-method study", Records Management Journal, Vol. 32 No. 3, pp. 288-320. https://doi.org/10.1108/RMJ-02-2022-0004
Publisher
:Emerald Publishing Limited
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