Background Electronic Medical Record (EMR) functions include electronic ordering of investigations and receiving results, electronic prescribing, recording of clinical information and decision support software. Despite substantial investment in EMR systems, there has been little research to evaluate them. Our aim was to evaluate changes in efficiency and quality of services after the introduction of a purpose built EMR system, and to assess its acceptability by the doctors, nurses and patients using it.
Methods We compared the number of patients seen per hour within nine month periods before and after the introduction of an EMR system in a large sexual health service, in Melbourne Australia. A sample of records from both EMR and Paper Medical Record (PMR) periods were audited by two physicians to evaluate quality and completeness of records. Staff and patients completed anonymous surveys about their satisfaction and experience with the EMR system.
Results There were 9,752 doctor consultations (in 5,512 consulting hours) in the PMR period and 9,145 doctor consultations (in 5,176 consulting hours) in the EMR period eligible for inclusion in the analysis. There were 5% more consultations per hour seen by doctors in the EMR period compared to the PMR period (rate ratio = 1.05; 95% confidence interval (CI); 1.02–1.08) after adjusting for type of consultation. The qualitative evaluation of 300 records for each period showed no difference in quality or completeness (P > 0.17). The survey of clinicians demonstrated that doctors and nurses preferred the EMR system (P < 0.01) and the patient survey in each period showed no difference in satisfaction of their care (97% for PMR, 95% for EMR, P = 0.61).
Conclusion The introduction of an integrated EMR improved efficiency while maintaining the quality of the patient record. The EMR was popular with staff and was not associated with a decline in patient satisfaction in clinical care provided.
- Clinical practice
- Electronic medical records