Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: An Iranian case study

Abstract

Objectives:Information technology is a rapidly expanding branch of science which has affected other sciences. One example of using information technology in medicine is the Electronic Medical Records system. One medical university in Iran decided to introduce such system in its hospital. This study was designed to identify the factors which influence the quality of medical documentation when paper-based records are replaced with electronic records.Methods:A set of 300 electronic medical records was randomly selected and evaluated against eleven checklists in terms of documentation of medical information, availability, accuracy and ease of use. To get the opinion of the care-providers on the electronic medical records system, ten physicians and ten nurses were interviewed by using of semi-structured guidelines. The results were also compared with a prior study with 300 paper-based medical records.Results:The quality of documentation of the medical records was improved in areas where nurses were involved, but those parts which needed physicians' involvement were actually worse. High workloads, shortage of bedside hardware and lack of software features were prominent influential factors in the quality of documentation. The results also indicate that the retrieval of information from the electronic medical records is easier and faster, especially in emergency situations.Conclusions:The electronic medical records system can be a good substitute for the paper-based medical records system. However, according to this study, some factors such as low physician acceptance of the electronic medical record system, lack of administrative mechanisms (for instance supervision, neglecting physicians and/or nurses in the development and implementation phases and also continuous training), availability of hardware as well as lack of specific software features can negatively affect transition from a paper-based system to an electronic system.