Healthc Inform Res.  2019 Apr;25(2):115-123. 10.4258/hir.2019.25.2.115.

Clinical Decision Support Functions and Digitalization of Clinical Documents of Electronic Medical Record Systems

Affiliations
  • 1Research Institute for Health Insurance Claims Review & Assessment, Health Insurance Review & Assessment Service, Wonju, Korea. pyt0601@hira.or.kr
  • 2Department of Nursing, California State University, San Bernardino, CA, USA.
  • 3Smart Healthcare & Device Research Center, Samsung Medical Center, Seoul, Korea.
  • 4Samsung Advanced Institute of Health Science and Technology, Sungkyunkwan University, Seoul, Korea.
  • 5Department of Big Data Analytics, Ewha Womans University, Seoul, Korea.

Abstract


OBJECTIVES
The objective of this study was to investigate the clinical decision support (CDS) functions and digitalization of clinical documents of Electronic Medical Record (EMR) systems in Korea. This exploratory study was conducted focusing on current status of EMR systems.
METHODS
This study used a nationwide survey on EMR systems conducted from July 25, 2018 to September 30, 2018 in Korea. The unit of analysis was hospitals. Respondents of the survey were mainly medical recorders or staff members in departments of health insurance claims or information technology. This study analyzed data acquired from 132 hospitals that participated in the survey.
RESULTS
This study found that approximately 80% of clinical documents were digitalized in both general and small hospitals. The percentages of general and small hospitals with 100% paperless medical charts were 33.7% and 38.2%, respectively. The EMR systems of general hospitals are more likely to have CDS functions of warnings regarding drug dosage, reminders of clinical schedules, and clinical guidelines compared to those of small hospitals; this difference was statistically significant. For the lists of digitalized clinical documents, almost 93% of EMR systems in general hospitals have the inpatient progress note, operation records, and discharge summary notes digitalized.
CONCLUSIONS
EMRs are becoming increasingly important. This study found that the functions and digital documentation of EMR systems still have a large gap, which should be improved and made more sophisticated. We hope that the results of this study will contribute to the development of more sophisticated EMR systems.

Keyword

Electronic Medical Records; Electronic Health Records; Computerized Medical Record Systems; Medical Informatics; Health Information Exchange

MeSH Terms

Appointments and Schedules
Decision Support Systems, Clinical*
Electronic Health Records*
Health Information Exchange
Hope
Hospitals, General
Humans
Inpatients
Insurance, Health
Korea
Medical Informatics
Medical Records
Medical Records Systems, Computerized
Surveys and Questionnaires

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Reference

1. Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009; 360(16):1628–1638.
Article
2. Holroyd-Leduc JM, Lorenzetti D, Straus SE, Sykes L, Quan H. The impact of the electronic medical record on structure, process, and outcomes within primary care: a systematic review of the evidence. J Am Med Inform Assoc. 2011; 18(6):732–737.
Article
3. Park YT, Han D. Current status of electronic medical record systems in hospitals and clinics in Korea. Healthc Inform Res. 2017; 23(3):189–198.
Article
4. Garrett P, Seidman J. EMR vs EHR – what is the difference? [Internet]. Washington (DC): The Office of the National Coordinator for Health Information Technology;c2019. cited at 2019 Apr 15. Available from: https://www.healthit.gov/buzz-blog/electronic-health-and-medical-records/emr-vs-ehr-difference.
5. Shachak A, Reis S. The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review. J Eval Clin Pract. 2009; 15(4):641–649.
Article
6. The Office of the National Coordinator for Health Information Technology (ONC). Clinical decision support [Internet]. Washington (DC): ONC;c2019. cited at 2019 Apr 15. Available from: https://www.healthit.gov/topic/safety/clinical-decision-support.
7. Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A roadmap for national action on clinical decision support. J Am Med Inform Assoc. 2007; 14(2):141–145.
Article
8. Middleton B, Bloomrosen M, Dente MA, Hashmat B, Koppel R, Overhage JM, et al. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. J Am Med Inform Assoc. 2013; 20(e1):e2–e8.
Article
9. Keenan GM, Lopez KD, Yao Y, Sousa VE, Stifter J, Febretti A, et al. Toward meaningful care plan clinical decision support: feasibility and effects of a simulated pilot study. Nurs Res. 2017; 66(5):388–398.
10. Park H, Lee SI, Hwang H, Kim Y, Heo EY, Kim JW, et al. Can a health information exchange save healthcare costs? Evidence from a pilot program in South Korea. Int J Med Inform. 2015; 84(9):658–666.
Article
11. Khairat S, Marc D, Crosby W, Al Sanousi A. Reasons for physicians not adopting clinical decision support systems: critical analysis. JMIR Med Inform. 2018; 6(2):e24.
Article
12. Thanathornwong B. Bayesian-based decision support system for assessing the needs for orthodontic treatment. Healthc Inform Res. 2018; 24(1):22–28.
Article
13. Jao CS, Hier DB. Clinical decision support systems: an effective pathway to reduce medical errors and improve patient safety. In : Jao C, editor. Decision support systems. London: IntechOpen;2010.
14. Scott IA, Pillans PI, Barras M, Morris C. Using EMR-enabled computerized decision support systems to reduce prescribing of potentially inappropriate medications: a narrative review. Ther Adv Drug Saf. 2018; 9(9):559–573.
Article
15. Adler-Milstein J, Holmgren AJ, Kralovec P, Worzala C, Searcy T, Patel V. Electronic health record adoption in US hospitals: the emergence of a digital “advanced use” divide. J Am Med Inform Assoc. 2017; 24(6):1142–1148.
Article
16. Berner ES, La Lande T. Clinical decision support systems: impacting the future of clinical decision making. In : Ball MJ, Weaver CA, Kiel JM, editors. Healthcare information management systems. New York (NY): Springer;2004. p. 463–477.
17. Institute of Medicine (US) Committee on Data Standards for Patient Safety. Key capabilities of an electronic health record system: letter report. Washington (DC): National Academies Press;2003.
18. Healthcare Information and Management Systems Society (HIMSS). EMR sophistication correlates to hospital quality data [Internet]. Chicago (IL): HIMSS;c2006. cited at 2019 Apr 15. Available from: https://www.himss.eu/content/himss-analytics-emr-sophistication-correlates-hospital-quality-data.
19. Tundia NL, Kelton CM, Cavanaugh TM, Guo JJ, Hanseman DJ, Heaton PC. The effect of electronic medical record system sophistication on preventive healthcare for women. J Am Med Inform Assoc. 2013; 20(2):268–276.
Article
20. Adler-Milstein J, DesRoches CM, Kralovec P, Foster G, Worzala C, Charles D, et al. Electronic health record adoption in US hospitals: progress continues, but challenges persist. Health Aff (Millwood). 2015; 34(12):2174–2180.
Article
21. Kim YG, Jung K, Park YT, Shin D, Cho SY, Yoon D, et al. Rate of electronic health record adoption in South Korea: a nation-wide survey. Int J Med Inform. 2017; 101:100–107.
Article
22. Kharrazi H, Gonzalez CP, Lowe KB, Huerta TR, Ford EW. Forecasting the maturation of electronic health record functions among US hospitals: retrospective analysis and predictive model. J Med Internet Res. 2018; 20(8):e10458.
Article
23. Lee YT, Park YT, Park JS, Yi BK. Association between electronic medical record system adoption and healthcare information technology infrastructure. Healthc Inform Res. 2018; 24(4):327–334.
Article
24. Steiner BA. Electronic medical record implementation in nursing practice: a literature review of the factors of success [dissertation]. Bozeman (MT): College of Nursing, Montana State University;2009.
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