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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.

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.

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.

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.

Ireland’s physicians have a legal and an ethical duty to protect confidential patient information. Most healthcare records in Ireland remain paper based, so the purpose of this paper is to: assess the protection afforded to paper records; log highest risk records; note the variations that occurred during the working week; and observe the varying protection that occurred when staff, students and public members were present.

A customised audit tool was created using Sphinx software. Data were collected for three months. All wards included in the study were visited once during four discrete time periods across the working week. The medical records trolley’s location was noted and total unattended medical records, total unattended nursing records, total unattended patient lists and when nursing personnel, medical students, public and a ward secretary were visibly present were recorded.

During 84 occasions when the authors visited wards, unattended medical records were identified on 33 per cent of occasions, 49 per cent were found during weekend visiting hours and just 4 per cent were found during morning rounds. The unattended medical records belonged to patients admitted to a medical specialty in 73 per cent of cases and a surgical specialty in 27 per cent. Medical records were found unattended in the nurses’ station with much greater frequency when the ward secretary was off duty. Unattended nursing records were identified on 67 per cent of occasions the authors visited the ward and were most commonly found unattended in groups of six or more.

This study is a timely reminder that confidential patient information is at risk from inappropriate disclosure in the hospital. There are few context-specific standards for data protection to guide healthcare professionals, particularly paper records. Nursing records are left unattended with twice the frequency of medical records and are found unattended in greater numbers than medical records. Protection is strongest when ward secretaries are on duty. Over-reliance on vigilant ward secretaries could represent a threat to confidential patient information.

While other studies identified data protection as an issue, this study assesses how data security varies inside and outside conventional working hours. It provides a rationale and an impetus for specific changes across the whole working week. By identifying the on-duty ward secretary’s favourable effect on medical record security, it highlights the need for alternative arrangements when the ward secretary is off duty. Data were collected prospectively in real time, giving a more accurate healthcare record security snapshot in each data collection point.

This study proposes targeted modernization of the Department of Defense (DoD's) Joint Forces Ammunition Logistics information system by implementing the optimized innovative information technology open architecture design and integrating Radio Frequency Identification Device data technologies and real-time optimization and control mechanisms as the critical technology components of the solution. The innovative information technology, which pursues the focused logistics, will be deployed in 36 months at the estimated cost of $568 million in constant dollars. We estimate that the Systems, Applications, Products (SAP)-based enterprise integration solution that the Army currently pursues will cost another $1.5 billion through the year 2014; however, it is unlikely to deliver the intended technical capabilities.

This paper seeks to analyze attempts, in the USA and globally, to create new and improved methods used to manage patient health information: electronic medical records (EHRs). This new system of records management is to be examined to determine the possible benefits for patients, providers, insurers, employers, and others, as well as barriers to the use of EHRs, particularly in those embedded in US law.

In the USA, and in various other jurisdictions, new laws have been enacted to incentivize the use of EHRs, and the paper examines the regulations and provisions incentivizing the adoption of this type of integrated system for lifelong tracking of health‐related information. There are issues to be dealt with, such as cost, privacy, and legality, but each of these can and must be overcome to effectively manage and communicate health care information

The use of EHRs is increasing in the USA and globally, both in acute care hospitals and in primary care medical practices, largely accomplished through positive incentives, and penalties for non‐compliance. There are also various countries well on the way to wide‐spread use of electronic health records management.

The use of EHRs creates a societal benefit, initially one on an individual level, but one which over time could rise to a level positively affecting health care on a national, even global level.

The paper is based on an analysis of relevant laws/regulations, best practices, and anecdotal/observational evidence. No empirical evidence survey or study was conducted, primarily because the process of implementation of EHRs is too new. It is of value to practitioners, policy makers, and interested public parties.

This study aims to develop a framework for the management of medical records in support of health-care service delivery in the hospitals in the Limpopo province of South Africa.

The study was predominantly quantitative and has used the questionnaires, system analysis, document analysis and observation to collect data in 40 hospitals of Limpopo province. The sample of 49 per cent (306) records management officials were drawn out of 622 (100 per cent) total population. The response rate was 71 per cent (217) out of the entire sample.

The study discovered that a framework for management of medical records in the public hospitals is not in place because of several reasons and further demonstrates that public health-care institutions need an integrative framework for the proper management of medical records of all forms and in all media.

The study develops and suggests a framework to embed medical records management into the health-care service delivery workflow for effective records management and ease of access. It is hoped that such a framework will help hospitals in South Africa and elsewhere to improve their medical records management to support health-care service provision.

This paper examines existing research on the topic of personal health records (PHRs). Areas covered include PHR/patient portal, recordkeeping, preservation planning, access and provider needs for future reuse of health information. Patient and physician PHR use and functionality, as well as adoption facilitators and barriers, are also reviewed.

The paper engages in a review of relevant literature from a variety of subject domains, including personal information management, medical informatics, medical literature and archives and records management literature.

The review finds that PHRs are extensions of electronic records. In addition, it finds a lack of literature within archives and records management that may lead to a less preservation-centric examination of the new PHR technologies that are desirable for controlling the lifecycle of these important new records-type.

Although the issues presented by PHRs are issues that can best be solved with the use of techniques from records management, there is no current literature related to PHRs in the records management literature, and that offered in the medical informatics literature treats the stewardship aspects of PHRs as insurmountable. This paper offers an introduction to the aspects of PHRs that could fruitfully be examined in archives and records management.

The purpose of this paper is to present the findings of a research study conducted to find the perceptions of medical professionals about reduction in medical errors using electronic medical records (EMRs). It presents the relationship between EMR use in medical facilities and the reduction in medical errors. The use of EMR can lead to competitive advantages in the health-care environment.

This paper is based upon the perceptions of 99 medical professionals who use EMR in their practice in Arizona, USA.

This paper presents the medical professionals who use EMR which reduces medical errors, wrong site surgery, improper dosage delivery to a patient, wrong medication, etc. by 50-60 per cent.

This paper is limited to perceived reductions in medical errors because the actual number of errors is either unavailable or medical professionals are unwilling to provide. Future research should seek conducting database searches to find medical malpractice lawsuits, unexpected costs or any reference to quantifying losses because of medical errors. Once the expenses are reported, relating to medical malpractice legal costs with the cost of investing in EMR system would prove an excellent observational study.

Medical professionals, medical facilities and patients should be aware of the impact EMRs have on the healthcare provided as well as the safety of patients enabled by the EMRs.

Health-care industry is operating in a crisis mode and before it turns chaotic, there needs to be a consistent product used by every health-care organization or practice. EMRs can automatically update patients’ information that is required on a routine basis via different computing systems such as cloud, minimizing the need for information technology professionals to handle the issues. This leads to reduced cost, increased efficiency, effectiveness and better management of the patients’ health and wellness outcomes, with perceived reduction in medical errors.

The value of this research report is to provide the various features EMR offers and how it helps to reduce medical mistakes that help in avoiding repetition of different tests, incorrect dosage delivery and interaction of various medicines a patient is taking.

The purpose of this article is to present a conceptual model that posits the strategic relationships between information technology, clinic operations and physicians and the subsequent outcomes to patients, physicians and clinics which can lead to competitive advantages in the healthcare environment.

This paper is based on a review of the literature and proposes a conceptual model of the strategic relationships essential for success. The scope of the paper is based on the legal, economic and political triggers impacting the strategic relationship between electronic medical records, clinic interoperability and physicians as owners/users.

The paper presents the formation of a conceptual model which identifies the strategic alignment between clinics, physicians and information technology, more specifically, electronic medical records.

This paper is limited in that it is not an empirical investigation but a conceptual model of future research endeavours. Future research endeavours should seek empirical findings related to the relationships proposed in the model.

Physicians, clinics and patients should be aware of the impact electronic medical records have on the health environment as well as the potential competitiveness due to health consumerism enabled by electronic medical records.

Electronic medical records, personal health records and electronic health records are infiltrating society; subsequently health consumers should determine how this technology may impact their healthcare.

The value of this paper is to provide a conceptual model as a basis for future empirical research and awareness of changes in the competitiveness of the healthcare environment.

The purpose of this paper is to show how a clinical decision support system can help in prescription and knowledge acquisition processes.

An integrated electronic medical records system (iEMRS) is designed to enhance the decision support quality in prescription.

By evaluating the system performance through 135 prescription records collected from a Hong Kong medical organization, iEMRS shows a satisfactory result in suggesting medicines that is properly the same as the decisions made by the physicians.

Compared with the static clinical guidelines built (manually) in the traditional clinical decision support system, knowledge in iEMRS is generated by the knowledge discovery result from professional experiences of various physicians and patient histories, which are more dynamic in nature. A treatment algorithm, designed in data mining technique, is introduced to improve information management in medical organizations by integration of decision support capability and EMRS, and supplement the deficiencies of traditional clinical decision support system.

This chapter proposes an optimized innovative information technology as a means for achieving operational functionalities of real-time portable electronic health records, system interoperability, longitudinal health-risks research cohort and surveillance of adverse events infrastructure, and clinical, genome regions – disease and interventional prevention infrastructure. In application to the Dod-VA (Department of Defense and Veteran's Administration) health information systems, the proposed modernization can be carried out as an “add-on” expansion (estimated at $288 million in constant dollars) or as a “stand-alone” innovative information technology system (estimated at $489.7 million), and either solution will prototype an infrastructure for nation-wide health information systems interoperability, portable real-time electronic health records (EHRs), adverse events surveillance, and interventional prevention based on targeted single nucleotide polymorphisms (SNPs) discovery.