Healthc Inform Res.  2019 Apr;25(2):115-123. 10.4258/hir.2019.25.2.115.

Clinical Decision Support Functions and Digitalization of Clinical Documents of Electronic Medical Record Systems

• Park YT
• Kim YS
• Yi BK
• Kim SM

• KMID: 2445008
• DOI: http://doi.org/10.4258/hir.2019.25.2.115

Abstract

OBJECTIVES
The objective of this study was to investigate the clinical decision support (CDS) functions and digitalization of clinical documents of Electronic Medical Record (EMR) systems in Korea. This exploratory study was conducted focusing on current status of EMR systems.
METHODS
This study used a nationwide survey on EMR systems conducted from July 25, 2018 to September 30, 2018 in Korea. The unit of analysis was hospitals. Respondents of the survey were mainly medical recorders or staff members in departments of health insurance claims or information technology. This study analyzed data acquired from 132 hospitals that participated in the survey.
RESULTS
This study found that approximately 80% of clinical documents were digitalized in both general and small hospitals. The percentages of general and small hospitals with 100% paperless medical charts were 33.7% and 38.2%, respectively. The EMR systems of general hospitals are more likely to have CDS functions of warnings regarding drug dosage, reminders of clinical schedules, and clinical guidelines compared to those of small hospitals; this difference was statistically significant. For the lists of digitalized clinical documents, almost 93% of EMR systems in general hospitals have the inpatient progress note, operation records, and discharge summary notes digitalized.
CONCLUSIONS
EMRs are becoming increasingly important. This study found that the functions and digital documentation of EMR systems still have a large gap, which should be improved and made more sophisticated. We hope that the results of this study will contribute to the development of more sophisticated EMR systems.

Keyword

Electronic Medical Records; Electronic Health Records; Computerized Medical Record Systems; Medical Informatics; Health Information Exchange

MeSH Terms

Appointments and Schedules
Decision Support Systems, Clinical*
Electronic Health Records*
Health Information Exchange
Hope
Hospitals, General
Humans
Inpatients
Insurance, Health
Korea
Medical Informatics
Medical Records
Medical Records Systems, Computerized
Surveys and Questionnaires

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