Processing medical data: a systematic review

Archives of Public Health

Kasaw Adane³  Dagnachew Muluye²  Molla Abebe¹ 

[1] Department of Clinical Chemistry, College of Medicine and Health Sciences, School of Biomedical and Laboratory Sciences, University of Gondar, Gondar, Ethiopia

[2] Department of Medical Microbiology, College of Medicine and Health Sciences, School of Biomedical and Laboratory Sciences, University of Gondar, Gondar, Ethiopia

[3] College of Medicine and Health Sciences, School of Biomedical and Laboratory Sciences, Unit of Laboratory Management and Quality Assurance, University of Gondar, Gondar, Ethiopia

关键词: Health service quality;    Electronic health record;    Decision making;    Documentation;    Medical data;   

Others  :  790676
DOI  :  10.1186/0778-7367-71-27

 received in 2013-04-30, accepted in 2013-10-02,  发布年份 2013

【 摘 要 】

Background

Medical data recording is one of the basic clinical tools. Electronic Health Record (EHR) is important for data processing, communication, efficiency and effectiveness of patients’ information access, confidentiality, ethical and/or legal issues. Clinical record promote and support communication among service providers and hence upscale quality of healthcare. Qualities of records are reflections of the quality of care patients offered.

Methods

Qualitative analysis was undertaken for this systematic review. We reviewed 40 materials Published from 1999 to 2013. We searched these materials from databases including ovidMEDLINE and ovidEMBASE. Two reviewers independently screened materials on medical data recording, documentation and information processing and communication. Finally, all selected references were summarized, reconciled and compiled as one compatible document.

Result

Patients were dying and/or getting much suffering as the result of poor quality medical records. Electronic health record minimizes errors, saves unnecessary time, and money wasted on processing medical data.

Conclusion

Many countries have been complaining for incompleteness, inappropriateness and illegibility of records. Therefore creating awareness on the magnitude of the problem has paramount importance. Hence available correct patient information has lots of potential in reducing errors and support roles.

【 授权许可】

   
2013 Adane et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]NCCLS: A Quality Management System Model for Health Care; Approved Guideline-Second Edition, NCCLS document HS1- A2, vol. 45. USA: NCCLS; 2004.
• [2]CLSI: Laboratory Documents: Development and control; Approved Guideline. Fifth edition. USA: CLSI document GP2-A5, CLSI; 2009:22.
• [3]Lange D: Digital Pathology: A Regulatory Overview. Labmed 2011, 42:587-591.
• [4]Woodcock S, Fine G, McClure K, Unger B, Rizzo P: The Role of Standards and Training in Preparing for Accreditation, Kigali Conference / Preparing for Accreditation. Am J Clin Pathol 2010, 134:388-392.
• [5]Stewart R: Healthcare clinical documentation-putting the house in order. Canada: Marsh & McLennan Companies; 2007.
• [6]NCCLS: Continuous Quality Improvement: Integrating Five Key Quality System Components; Approved Guideline—Second Edition: NCCLS document GP22-A2, vol. 24. USA: NCCLS; 2004.
• [7]Pullen I, Loudon J: Improving standards in clinical record-keeping. Advances in Psychiatric Treatment. England 2006, 12:280-286.
• [8]NCCLS: Application of a Quality Management System Model for Laboratory Services; Approved Guideline—Third Edition, NCCLS document GP26-A3, vol. 24. USA: NCCLS; 2004.
• [9]WHO-SEARO: Guidelines for Medical Record and Clinical Documentation coding workshop. Geneva: WHO; 2007.
• [10]NCCLS: Clinical Laboratory Technical Procedure Manuals; Approved Guideline. Fourth edition. USA: NCCLS document GP2-A4; 2002:22.
• [11]Yeo G: Managing Hospital Records. UK: International Records Management Trust and International Council on Archieves; 1999. Version 1
• [12]European Medicines Agency: Note for the Guidance on Good Clinical Practice. London: CPMP/ICH/135/95; 2006.
• [13]Stimpfel N: Quality Medical Charts: The Importance of Proper Medical Record Documentation. New York: TransforMED™; 2008.
• [14]World Health Organization: Medical Records Manual: A Guide for Developing Countries. Geneva: WHO; 2002.
• [15]World Health Organization: Improving Data Quality: A Guide for Developing Countries. Geneva: World Health Organization Regional Office for the Western Pacific; 2003.
• [16]Harmening D: Laboratory management principles and processes. 2nd edition. Florida, USA: Pearson’s education Inc; 2007:283-302.
• [17]World Health Organization: mHealth: New horizons for health through mobile Technologies. Based on the findings of the second global survey on eHealth. Geneva: WHO; 2011.
• [18]NCCLS: Clinical Laboratory Standard Institute: Quality Manual Approved Guideline. Third edition. USA: NCCLS; 2006.
• [19]Blobel B, Roger-France F: A systematic approach for analysis and design of secure health information systems. ELSEVIER, Int J med info 2001, 62:51-78.
• [20]Bordowitz R: Electronic Health Records: A Primer. Labmed 2008, 39:301-306.
• [21]Pantanowitz L, Brodsky V, Aller R: Laboratory Reports in the Electronic Medical Record. Labmed 2007, 38:339-340.
• [22]Armijo D, McDonnell C, Werner K: Electronic Health Record Usability: Evaluation and Use Case Framework. USA: AHRQ Publication No. 09(10)-0091-1-EF; 2009.
• [23]Cysneiros M, Leite P, Neto J: A Framework for Integrating Non-Functional Requirements into Conceptual Models. Req Eng J 2001, 6:97-115.
• [24]New York State Department of Health: Guidance for Implementing a Laboratory Quality Management System. New York: USA: New York State Department of Health; 2010.
• [25]Embi PJ, Weir C, Efthimiadis EN, Thiele SM, Hedeen AN, Hammond KW: Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators. J Am Med Inform Assoc 2013, 20:718-726.
• [26]Weingart S, Wilson R, Gibberd R, Harrison B: Epidemiology of medical error. BMJ 2000, 320:774-777.
• [27]Hartel M, Staub L, Röder C, Eggli S: High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process. BMC Health Serv Res 2011, 11:199. BioMed Central Full Text
• [28]Staes C, Bennett S, Evans S, Narus S, Huff S, Sorensen J: A Case for Manual Entry of Structured, Coded Laboratory Data from Multiple Sources into an Ambulatory Electronic Health Record. J Am Med Inform Assoc 2006, 13:12-15.
• [29]Gershy-Damet GM, Rotz P, Cross D, Belabbes EH, Cham F, Ndihokubwayo JB, Fine J, Zen C, Njukeng PA, Mboup S, Sesse DE, Messele T, Birx DL, Nkengasong JN: Improving the Quality of Laboratory Systems in the African Region, Kigali Conference. Am J Clin Pathol 2010, 134:393-400.
• [30]Snyder-Halpern R: Indicators of organizational readiness for clinical information technology/systems innovation: a Delphi study. Int J Med Info 2001, 63:179-204.
• [31]Blaya JA, Shin SS, Yagui MJ, Yale G, Suarez CZ, Asencios LL, Cegielski JP, Frazer HS: A web-based laboratory information system to improve quality of care of tuberculosis patients in Peru: functional requirements, implementation and usage statistics. BMC Med Inform Decis Mak 2007, 7:33. BioMed Central Full Text
• [32]Armenta A, Eichner M, Kallabis B, Lovens P: A Case of Study on Linköpings University Hospital Information System. Sweden: Linköpings University Hospital; 2001.
• [33]Guojun Y, Ying Z, Gang W: An Application Research on the Workflow-based Large-scale Hospital Information System Integration. Journal of Computers 2011, 6:106-113.
• [34]Bodek H: Standards for Clinical Documentation and Recordkeeping. NY: NY State Society for Clinical Social Work, Inc.; 2010.
• [35]Hillestad R, Bigelow J, Bower A, Girosi F, Meili R, Scoville R, Taylor R: Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits: Savings, And Costs, Health Affairs. USA 2005, 24:1103-1117.
• [36]Pourasghar F, Malekafzali H, Kazemi A, Ellenius J, Fors U: What they fill in today, may not be useful tomorrow: Lessons learned from studying Medical Record at the Women Hospital in Tabriz, Iran. BMC public Health 2008, 8:139. BioMed Central Full Text
• [37]Bob I, Greenley S, Kimani J, Macias L, Ndung’u MN, Rhine L: Improving Health, Connecting People: The Role of ICTs in the Health Sector of Developing Countries. UK: Working Paper NO. 7 Infodev; 2006.
• [38]World Health Organization: Telemedicine: opportunities and developments in Member States: report on the second global survey on eHealth 2009. Geneva: WHO; 2010.
• [39]Cheng JL, Chang TK: “Telemedicine in East of Taiwan” in Materna B, (Ed.) Advances in International and eHealth around the World. Poland: MediPage Ltd 2006, 1:152-158.
• [40]Burney A, Abbas Z, Mohamood N, Arifeen Q: Prospects for Mobile Health in Pakistan and Other Developing Countries. Pakistan; Advances in Internet of Things 2013, 3:27-32.