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

The present computer system is the first of its kind based on problem-orien ted medical record (POMR) design developed and operated in a hospital in Ho ng Kong. It went live in May 1996 with two workstations installed in the me dical record office (MRO). Doctors have no direct access to it. They dictat e medical notes on tape using either structured or free dictation format, a nd the tape is brought to the MRO for processing. The principal aim of this study is to study the impact of the computer system on patient care. Retro spective review of medical records and in-depth interviews were conducted t o study the quality of medical records and doctor's opinions. A total of 40 0 manual and 398 computerized patient records were randomly selected for re view. The completeness of the manual notes and computerized notes using fre e dictation format were about the same. The computerized records using stru ctured dictation format may be more complete than those using free dictatio n format. The in-depth interview shows that most doctors preferred structur ed medical records but some disagreed with too detailed a level of structur ing. They were not familiar with POMR, and some even thought that breaking down the record by problem was not possible. AU felt that the present syste m would not directly affect patient care, but some said that it would facil itate research. In conclusion, since the utility of the information mainly depends on the doctors' efforts, commitment to the agreed structure and sub sequent routine audit of computerized medical records are essential to make sure that diagnoses are accurately coded and information is correctly stru ctured. (C) 1999 Elsevier Science Ireland Ltd. All rights reserved.