Document Type

Article

Publication Date

4-2019

Publication Title

Healthcare Informatics Research

Volume

25

Issue

2

First Page

115

Last Page

123

DOI

10.4258/hir.2019.25.2.115

ISSN

2093-3681

Keywords

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

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.

Rights

This is the archived version of an open-access article originally published at https://www.e-hir.org/DOIx.php?id=10.4258/hir.2019.25.2.115 by the Korean Society of Medical Informatics.

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