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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.

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.

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.

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.

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.

The Audit Commission is the statutory body which oversees the external audit of local authorities and agencies within the National Health Service in England and Wales. As part of its function the Commission reviews the economy, efficiency and effectiveness of services provided by these bodies by undertaking studies and audits of selected topics each year. The study of medical records was one of these.

The purpose of this study is to determine the extent to which total quality management (TQM) initiatives can improve the quality of services delivery at the medical records unit of the Korle-Bu Teaching Hospital (KBTH) to help meet the expectations and aspirations of patients and customers of the hospital.

This research adopted the survey strategy as its research design. The total study population consisted of 114 medical records staff of the KBTH. Questionnaires and personal observations were employed as the data collection instruments. The study recorded a response rate of 98 per cent. Data gathered from respondents were analysed in qualitative terms.

The overall finding of this study was that, although the medical records department of the KBTH had a fair degree of understanding on the benefits of TQM to records management service delivery, the exiting values for TQM did not meet the framework of good TQM practice, principles and standards.

Even though the subjects for the study were from the biggest hospital in Ghana, the findings of this study may not be generalised to the whole country.

The study has demonstrated the need for the medical records department of the KBTH to have and develop good TQM standards to improve the quality of services to patients and varied customers of the hospital.

The literature reviewed indicated that this study is a maiden attempt to examine how TQM initiatives including sensitivity, customer satisfaction, commitment of top management, team work, effective leadership and participatory management, people development and effective and open communication can improve the quality of medical records service delivery at the KBTH in Ghana.

The purpose of this paper is to present an automatic Medical Knowledge Elicitation System (MediKES), which is designed to improve elicitation and sharing of tacit knowledge acquired by physicians. The system leverages the clinical information stored in electronic medical record systems, by representing the acquired information in a series of knowledge maps.

The system architecture of the proposed MediKES is first discussed, and then a case study on an application of the proposed system in a Hong Kong medical organization is presented to illustrate the adoption process and highlight the benefits that can be realized from deployment of the MediKES.

The results of the case study show that the proposed solution is more reliable and powerful than traditional knowledge elicitation approaches in capturing physicians' tacit knowledge, transforming it into a machine‐readable form, as well as enhancing the quality of the medical judgment made by physicians.

A prototype system has been constructed and implemented on a trial basis in a medical organization. It has proven to be of benefit to healthcare professionals through its automatic functions in representing and visualizing physicians' diagnostic decisions.

Knowledge is key to improving the quality of the medical judgment of physicians. However, researchers and practitioners are still striving for more effective ways of capturing tacit knowledge and transforming it into a machine‐readable form so as to enhance knowledge sharing. In this paper, the authors reveal that the knowledge retrieval and the visual knowledge representation functions of the proposed system are able to facilitate knowledge sharing among physicians. Thus, junior physicians can use it as a decision support tool in making better diagnostic decisions.

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.