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Medical record represents the main information support used by healthcare providers. The purpose of this paper is to examine whether patient perception of hospital care quality related to compliance with medical-record keeping.

The authors merged the original data collected as part of a nationwide audit of medical records with overall and subscale perception scores (range 0-100, with higher scores denoting better rating) computed for 191 respondents to a cross-sectional survey of patients discharged from a university hospital.

The median overall patient perception score was 77 (25th-75th percentiles, 68-87) and differed according to the presence of discharge summary completed within eight days of discharge (81 v. 75, p=0.03 after adjusting for baseline patient and hospital stay characteristics). No independent associations were found between patient perception scores and the documentation of pain assessment and nutritional disorder screening. Yet, medical record-keeping quality was independently associated with higher patient perception scores for the nurses’ interpersonal and technical skills component.

First, this was a single-center study conducted in a large full-teaching hospital and the findings may not apply to other facilities. Second, the analysis might be underpowered to detect small but clinically significant differences in patient perception scores according to compliance with recording standards. Third, the authors could not investigate whether electronic medical record contributed to better compliance with recording standards and eventually higher patient perception scores.

Because of the potential consequences of poor recording for patient safety, further efforts are warranted to improve the accuracy and completeness of documentation in medical records.

A modest relationship exists between the quality of medical-record keeping and patient perception of hospital care.

The purpose of the paper is to determine the instance of errors made in physician dictation of medical records.

Purposive sampling method was employed to select medical transcriptionists (MTs) as “experts” to identify the frequency and types of medical errors in dictation files. Seventy-nine MTs examined 2,391 dictation files during one standard work day, and used a common template to record errors.

The results demonstrated that on the average, on the order of 315,000 errors in one million dictations were surfaced. This shows that medical errors occur in dictation, and quality assurance measures are needed in dealing with those errors.

There was no potential for inter-coder reliability and confirming the error codes assigned by individual MTs. This study only examined the presence of errors in the dictation-transcription model. Finally, the project was done with the cooperation of MTSOs and transcription industry organizations.

Anecdotal evidence points to the belief that records created directly by physicians alone will have fewer errors and thus be more accurate. This research demonstrates this is not necessarily the case when it comes to physician dictation. As a result, the place of quality assurance in the medical record production workflow needs to be carefully considered before implementing a “once-and-done” (i.e. physician-based) model of record creation.

No other research has been published on the presence of errors or classification of errors in physician dictation. The paper questions the assumption that direct physician creation of medical records in the absence of secondary QA processes will result in higher quality documentation and fewer medical errors.

The aim of the paper is the study of information systems as mechanisms to manage existing and widespread knowledge in health care organizations; this is a platform that supports the processes of communication and knowledge sharing. The paper seeks to focus on the electronic medical record (EMR) as a tool to manage the integration of knowledge and operational information among health care through the coordination of the interdependencies.

The paper develops a methodology characterized by a mixed theoretical and analyzing the key documents on the context and literature on health information systems and an empirical part based on the use of semi‐structured interviews and questionnaires to the working group responsible for the project “medical records”.

The contributions of research can be found in the descriptive analysis obtained by the process of implementation of integrated medical records (IMRs) within the structures investigated. This can lead to highlight possible areas for improvement in the management of the construction and operation of the EMR.

The originality lies in the possibility of verifying the conditions of effective integration of knowledge to manage health problems, through the use of IMR as a mechanism for additional information. Possible value added is the description and encoding of knowledge available within the health departments.

This paper aims to investigate the perception of Egyptian patients about the use of personal health records (PHRs).

A quantitative research methodology was adopted in the form of a survey.

Over one-third of the selected sample was found to use PHRs. The study found that the use of PHRs by Egyptian patients was moderate. All PHRs users confirmed that they were very interested in the doctors’ notes and the laboratory reports recorded in their records. A very large number of PHR users confirmed that their use of these records was at least fairly easy for them and all of them confirmed that the use of these records was at least fairly useful. Above two-third of PHR users answered at least “somewhat yes” that their PHRs were accurate and over half of them answered at least “somewhat yes” that their PHRs were complete. The highest percentage of PHR users agreed that the use of PHRs would enhance their trust in their doctors and nurses. Close to half of PHR users expressed some concern about sharing their records. Violation of privacy in the use of these medical records, followed by the complexity of using them, as well as lack of awareness about them, was also significant to PHR users.

Understanding Egyptian patients perceptions of using PHRs may significantly aid in eliminating barriers and accelerating the adoption and use of these records to improve patient care.

The purpose of this paper is to understand the time spent on various tasks during physician inpatient rounds and to examine the new electronic health records (EHRs) impact on time distribution.

Trained observers shadowed hospital physicians to record times for various tasks before and after EHR implementation.

Electronic records did not improve efficiency. However, task times were redistributed. Physicians spent more time reviewing patient charts using time saved from miscellaneous work.

The study focusses solely on work distribution and the changes it underwent. It does not include quality measures either on patient results or physician satisfaction.

As EHR provides rich information and easier access to patient records, it motivates physicians to spend more time reviewing patient charts. Hospital administrators seeking immediate returns on EHR investment, therefore, may be disappointed.

Unlike previous work, this study was conducted in a non-teaching hospital, providing a task-time comparison without any educational and team factor influence. The result serves as a benchmark for many community hospital managers seeking to address the same issue.

The purpose of this paper is to explore the challenges of transforming South Africa’s health sector through the country’s eHealth Strategy and particularly one of its key components, the implementation of an integrated Electronic Document and Records Management System (EDRMS).

The study conducted an extensive review of literature and used it as a basis to analyse the challenges as well as opportunities in South Africa’s transformation path within its health sector based on the nation’s eHealth Strategy.

South Africa’s health sector faces three main transformation challenges: inequity, legacy of fragmentation and a service delivery structure biased towards curative rather than preventive services. Health information systems provide a solid platform for improving efficiency but, within South Africa, these systems have been highly heterogeneous. A recent study showed the country had more than 40 individual health information systems scattered in all provinces, with over 50 per cent not adhering to any national or international standards and more than 25 per cent being stand-alone applications that shared information neither locally nor externally. The eHealth Strategy offers a robust platform to start addressing the legacy of fragmentation and lack of interoperability. However, it also raises a few other concerns, including the use of different terminology such as Electronic Medical Record (EMR) interchangeable with Electronic Health Record (EHR), or EDRMS parallel with Electronic Content Management (ECM). In addition, there is the opportunity to explore the use of the maturity model concept in the EDRMS implementation experiences within South Africa.

This paper demonstrated the complex nature of the legacy of fragmentation in South Africa’s health information systems and explored three aspects relating to terminology as well as maturity models that should be considered in the country’s future eHealth Strategy.

The purpose of this paper is to investigate the elements that health care personnel in Thailand believe are necessary for successful adoption of electronic medical record (EMR) systems.

Initial qualitative in-depth interviews with physicians to adapt key elements from the literature to the Thai context. The 12 elements identified included things related to managing the implementation and to IT expertise. The nationwide survey was supported by the Ministry of Public Health and returned 1,069 usable questionnaires (response rate 42 percent) from a range of medical personnel.

The key elements clearly separated into a managerial dimension and an IT dimension. All were considered fairly important, but managerial expertise was more critical. In particular, there should be clear EMR project goals and scope, adequate budget allocation, clinical staff must be involved in implementation, and the IT should facilitate good electronic communication.

Thailand is representative of middle-income developing countries, but there is no guarantee findings can be generalized. National policies differ, as do economic structures of health care industries. The focus is on management at the organizational level, but future research must also examine macro-level issues, as well as gain more depth into thinking of individual health care personnel.

Technical issues of EMR implementation are certainly important. However, it is clear actual adoption and use of the system also depends very heavily on managerial issues.

Most research on EMR implementation has been in developed countries, and has often focussed more on technical issues rather than examining managerial issues closely. Health IT is also critical in developing economies, and management of health IT implementation must be well understood.

This paper aims to, by looking at the electronic medical record (EMR) from three points of view, bring light to the dynamics that are essential and are currently missing in the USA. The traditional paper medical record has worked for physicians, management and patients since the beginning of practice. Yet the development of the EMR did not begin with all the essential elements of the traditional record that were working, but instead shreds out important aspects of the patient.

Triangulation between three studies – medical, information technology and management studies.

An efficient EMR has to take into consideration more than just one area of study. The dynamics between departments and users of the EMR need an integrated process that includes the necessary pieces of all involved. This hole has not been addressed in academic literature.

The paper triangulates three areas – medicine, management and information management. Most research on the EMR focuses only on one or two of these areas’ concerns. Looking at the three sides of the EMR is important to get a solid understanding of the dynamics that can occur relaying a patient’s story through various departments and uses.

There is a depth, space and volume crucial to the comprehensive nature of medicine. With a perspective or dimension, necessary dialogues can be addressed and more intuitive tacit knowledge from medical expertise can be made available. A prototype, filling the holes of the observed elements in this paper, is possible by using digital objects and including more information than the data of the day. Bringing accountability to the patient, more expertise to the fingertips of the physician and available data for management purposes area are the key ingredients for an effective EMR.

With a comprehensive EMR that works more effectively for those who input the data, the patient’s story can be documented with more detailed efficiency. Filling the holes of the observed elements in this paper all support better healthcare and long-term results for the health of society.

The paper triangulates three areas – medicine, management and information management. Most research on the EMR focuses only on one or two of these areas’ concerns. Looking at the three sides of the EMR is important to get a solid understanding of the dynamics that can occur relaying a patient’s story through various departments and uses.