The application of a computerized problem-oriented medical record system and its impact on patient care

Introduction: The Problem-oriented medical record (POMR) structure was introduced by Weed over 30 years ago, but it is still new in Hong Kong. The present computer system is the first of its kind based on POMR design developed and operated in a hospital in Hong Kong. Aims: The aim of this study is to study the impact of the computer system on patient care. Scope of the system: The system went live in May 1996 with two workstations installed in the Medical Record Office (MRO). Doctors have no direct access to it. They dictate medical notes on tape. Then the tape is brought to the MRO where the staff transcribe the dictation, type into the system, and produce hardcopy for filing. Methods: It is argued that the impact of the system on patient care is essentially indirect. Based upon the features of the system, outcome measures were constructed, including quality of medical records and doctor's opinions. Retrospective review of medical records and in-depth interviews were conducted. Results: A total of 400 manual and 398 computerized patient records were randomly selected and reviewed. Of the 398 computerized records, 342 (86%) and 56 (14%) notes were dictated in the structured format and free format respectively in the first consultation, 389 (63%) and 231 (37%) notes were dictated in the structured format and free format respectively in the subsequent consultation. The percentages of the completeness of the manual notes and the computerized notes using free dictation format were about the same. The computerized records using structured dictation format may be more complete than those using free dictation format in terms of the patient complaint (39% vs. 32%) and the management plan (90% vs. 86%). On the contrary, the follow-up/admission date was more often found in the free format records (96%) than in the structured records (90%). Of those notes with information about the management plan and/or follow-up/admission date, over 98% of the notes using free dictation format had this information at the end, but only 74% of the notes using structured dictation format had it in the appropriate fields. Some doctors found the dictation guideline clumsy because not all headings were relevant to some patients. Most of the doctors preferred structured medical records but some disagreed with too detailed a level of structuring. Most doctors were not familiar with POMR, and some even thought that breaking down the record by problem was not possible because the problems were inter-related. All felt that the present system would not directly affect the care given to their patients, but some said that it would facilitate research. Discussion and conclusions: The ease of use of the computerized records was limited by the current stage of development of the system. In the future, paper records should be eliminated, and the doctors should have direct access to the computerized records from computer terminals. Moreover other clinical information, such as x-ray films and laboratory results, should be computerized as well. The utility of the information mainly depends on the doctors' efforts. Even if the diagnoses are coded, if they are coded inaccurately, the use of the codes is very limited. The same is true of the structuring of information. If the information is not structured correctly, the potential benefits of the information are seriously harmed. The main barrier to the implementation of the system was doctors' behaviours. First, they did not have sufficient knowledge and/or acceptance of the POMR concept. Second, they did not structure the information correctly, and finally the accuracy of the diagnosis codes is perceived to be doubtful. Commitment to the agreed structure and subsequent routine audit of computerized medical records are essential to make sure that diagnoses are accurately coded and information is correctly structured.