Electronic health records implementation: An evaluation of information system impact and contingency factors

Nguyen, Lemai; Bellucci, Emilia; Nguyen, Linh T.

doi:10.1016/j.ijmedinf.2014.06.011

Cited by 384 publications

(387 citation statements)

References 76 publications

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“…Destaca-se o estudo de Nguyen et al 19 , que realizou uma revisão sistemática e salientou os benefícios de obter documentação mais completa e redução da dependência dos médicos sobre a memória para recuperar dados de um paciente quando ocorre a transferência dos prontuários manuais para informatizados. No entanto, a mesma revisão identificou como impactos negativos o aumento do tempo de documentação, aumento da dependência de tecnologia e tempo gasto em computadores 19 .…”

Section: Discussionunclassified

“…Para tal, no ano de 2002, o Conselho Federal de Medicina editou a Resolução n º 1.638, passando a exigir a criação de comissões de revisão de prontuários, às quais competem: a observação dos itens que são obrigatórios nos prontuários, a garantia da legibilidade da letra em prontuários manuais e a responsabilidade do preenchimento, armazenamento e manuseio dos referidos documentos 29 . Nesse sentido, a melhoria da qualidade do registro em saúde, mediante o incentivo à estruturação da chamada "informática médica", com fichas eletrônicas padronizadas provendo campos obrigatórios que facilitem a coleta de informações essenciais aos serviços de saúde, tem como finalidade aperfeiçoar o armazenamento, a recuperação e o gerenciamento dessas informações 19,30,31 . Estudos pontuam que a aplicação de protocolos eletrônicos ainda é limitada devido aos custos dos equipamentos para implementação e manutenção, à falta de mão de obra qualificada e à possível resistência dos profissionais ao uso da informática 27,32 .…”

Section: Discussionunclassified

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Completude das informações do registro hospitalar de câncer em um hospital de Florianópolis

Luz¹,

Deitos²,

Siqueira³

et al. 2017

ABCS Health Sci.

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Introdução: O Registro Hospitalar de Câncer (RHC) é uma fonte sistemática de informação que visa ao aprimoramento do serviço prestado a todo paciente oncológico. Seus dados são essenciais para todos os profissionais que assistem ao paciente com neoplasia, uma vez que fornece informações sobre os procedimentos aplicados, permitindo elaborar o perfil de pacientes e direcionar a terapêutica a ser adotada. Objetivo: Avaliar a completude do preenchimento dos prontuários oncológicos da Maternidade Carmela Dutra nos anos de 2009 e 2010, com base nas variáveis do RHC. Métodos: Estudo descritivo exploratório, com dados de um banco secundário fornecido pelo RHC. Para análise dos prontuários foram utilizados pontos de corte identificando graus de incompletude de informações. Resultados: Dos 405 registros analisados, 8,9% estão na categoria ruim, 22,7% foram classificados como regular, 32,6% como bom e 35,8% na categoria excelente. Histórico familiar de câncer e etilismo permanece em grande parte dos casos ausentes nos prontuários. Conclusão: Evidencia-se a importância e a necessidade de melhoria dos registros médicos, com a estruturação de campos obrigatórios e a padronização do sistema de prontuários.Palavras-chave: oncologia; epidemiologia; sistemas de informação em saúde; registros de doenças. ABSTRACT Introduction:The Hospital Cancer Registry (HCR) is a systematic source of information aimed to improve the service provided to all cancer patients. Its database is essential for all professionals who attend to patients with cancer as it provides statistical data that allows to determinate the profile of patients, and so to direct the therapy to be adopted. Objective: To evaluate the completeness of the clinical and surgical oncology medical records of Maternity Carmela Dutra in 2009 and 2010, based on the variables of the HCR. Methods: A descriptive exploratory study was conducted with a secondary database provided by HCR. Cutoff points with different degrees were used for analysis of incompleteness of information from medical records. Results: Of the 405 records analyzed, 8.9% were in the poor category, 22.7% were classified in the fair category, 32.6% in the good and 35.8% in the excellent category. Family history of cancer and alcohol consumption remained largely the missing cases in the medical records. Conclusion: This study highlights the importance and need for improvement of medical records, with the structuring of required fields and standardization of medical records system.

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Section: Discussionunclassified

Completude das informações do registro hospitalar de câncer em um hospital de Florianópolis

Luz¹,

Deitos²,

Siqueira³

et al. 2017

ABCS Health Sci.

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show abstract

“…The system does not support continuity of care. There is no transparent universal referral or tracking of patient data which affects the quality of overall healthcare and compounds treatment costs due to possible duplication [18]. Collaboration mechanism between agencies, departments within the health sector and external institutions tend to be uncooperative.…”

Section: Health Systems and Policy Research Issn 2254-9137mentioning

confidence: 99%

“…These systems offer improved communication and access to services. An e-health record allows patients, medical staff, hospitals, and other health-care providers to view and share the patient's health information, with patients' prior consent [18]. Information of complete medication therapy, hospital discharge records, allergies, and immunisations may all …”

Section: Implications For Health Policymentioning

confidence: 99%

Comparing the Australian national health system with the Vietnamese national health system from the perspective of future challenges

Nguyen¹

2017

Health Syst Policy Res

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“…As illustrated by the model in Figure 3, such actions are very often confounded by the social environment of the work place. Orlikowski (1992) A study by Nguyen et al (2014) also strongly suggests that socio-technical connectives between users and technology should be considered when developing electronic health systems.…”

Section: Complex Sociocultural and Economic Factorsmentioning

confidence: 99%

Decision support systems for adoption in dental clinics: A survey

Goh

Tao

et al. 2016

Knowledge-Based Systems

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While most dental clinicians use some sort of information system, they are involved with administrative functions, despite the advisory potential of some of these systems. This paper outlines some current decision support systems (DSS) and the common barriers facing dentists in adopting them within their workflow. These barriers include lack of perceived usefulness, complicated social and economic factors, and the difficulty for users to interpret the advice given by the system. A survey of current systems found that although there are systems that suggest treatment options, there is no real-time integration with other knowledge bases. Additionally, advice on drug prescription at point-of-care is absent from such systems, which is a significant omission, in consideration of the fact that disease management and drug prescription are common in the workflow of a dentist. This paper also addresses future trends in the research and development of dental clinical DSS, with specific emphasis on big data, standards and privacy issues to fulfil the vision of a robust, user-friendly and scalable personalised DSS for dentists. The findings of this study will offer strategies in design, research and development of a DSS with sufficient perceived usefulness to attract adoption and integration by dentists within their routine clinical workflow, thus resulting in better health outcomes for patients and increased productivity for the clinic.

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Electronic health records implementation: An evaluation of information system impact and contingency factors

Cited by 384 publications

References 76 publications

Completude das informações do registro hospitalar de câncer em um hospital de Florianópolis

Completude das informações do registro hospitalar de câncer em um hospital de Florianópolis

Comparing the Australian national health system with the Vietnamese national health system from the perspective of future challenges

Decision support systems for adoption in dental clinics: A survey

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