Electronic Medical Records

The implications of intergovernmental agencies may forever change the way in which governments provide common services within a federated Australia. As governments seek to reduce duplication and inconsistencies across state and territory borders, intergovernmental agencies, born out of intergovernmental agreements, without any link to specific state or territory legislation, are challenging managers to develop, new approaches to procurement and implement information systems within this new legal dynamic framework. This paper considers the implications to managing health related records and their IT systems, having common legislative obligations across all Australia jurisdictions, to determine whether these new forms of government allow for the disposal of information, aimed at saving costs, improving the quality of data and reduce litigious risk. The paper also investigates the more general implications for any organisation operating nationally, to data sovereignty and how legislati...

Cardiorespiratory fitness (CRF) is an independent predictor of morbidity and mortality. In Japan, annual physical exams are mandatory in workplace settings, and most healthcare settings have electronic medical records (EMRs). However, in both settings, CRF is not usually determined, thereby limiting the potential for epidemiological investigations using EMR data. PURPOSE: To estimate CRF (mL/kg/min) using variables commonly recorded in EMRs. METHODS: Participants were 5293 Japanese adults (11.7% women) who completed an annual physical exam at a large gas company in Tokyo, Japan, in 2004. The mean age was 48.3 ± 8.0 years. Estimated CRF (eCRF) was based on age, measured body mass index, resting heart rate, systolic and diastolic blood pressure, and smoking. Measured CRF was determined by a submaximal cycle ergometer graded exercise test. RESULTS: Regression models were used for males and females to calculate Pearson’s correlation and regression coefficients. Cross-classification of measured CRF and eCRF was conducted using the lowest quintile, quartile, and tertile as the unfit categories. R’s for eCRF were 0.61 (MD 4.41) for men and 0.64 (MD 4.22) for women. The overall accuracy level was reasonable and consistent across models, yet the unfit lower tertile model provided the best overall model when considering the positive predictive value and sensitivity. CONCLUSION: eCRF may provide a useful method for conducting investigations using data derived from EMRs or datasets devoid of CRF or physical activity measures.

INTRODUCTION The promise of the electronic medical records lies in its ability to reduce the costs of health care delivery and improve the overall quality of care through more efficient management of patients’ records and reduction of space required for storage of patients’ files. Objectives Broad objective To determine the effectiveness of the Electronic Medical Records System at Kapkatet Hospital Specific objectives To determine the benefits of Electronic Medical Records System To determine the challenges facing the use of Electronic Medical Records System Methodology Study area: Kapkatet Hospital. Study population: The total population of the study was 45. Study design: Descriptive Cross-sectional study design. Data analysis and presentation: Qualitative data analysis Descriptive statistics have been applied using tables and graphs Dissemination of findings: Data was disseminated through an oral presentation and submission of a written report . Findings: Benefits the electronic m...

Artificial intelligence, blockchain and other potentially disruptive technologies form the crucial innovation, structural and institutional foundation for not only economic development, but also moral development and practical ethics. The integration of blockchain and AI [artificial intelligence] into a decentralized intelligence system has profound possibilities to employ data in innovative ways. An effective amalgamation of both technologies with IoT [internet of things] devices will enable faster and seamless data management, validation of transactions and detection of illegal activities, among others.

When most patients visit physicians in a clinic or a hospital, they are asked about their medical history and related medical tests’ results which might not exist or might simply have been lost over time. In emergency situations, many patients suffer or sadly die because of lack of pertinent medical information. Patient’s Health information (PHI) saved by Electronic Medical Record (EMR) could be accessible only by a hospital using their EMR system. Furthermore, Personal Health Record (PHR) information cannot be solely relied on since it is controlled solely by patients. This paper introduces a novel framework for accessing, sharing, and controlling the medical records for patients and their physicians globally, while patients’ PHI are securely stored and their privacy is taken into consideration. Based on the framework, a proof of concept prototype is implemented. Preliminary performance evaluation results indicate the validity and viability of the proposed framework

Electronic Medical Record (Emr) Systems Are Bei
ng Implemented Increasingly Worldwide. Saudi Arabia Is
One Of Developing Countries That Commenced Implementing Such Systems In 1988. Whilst Emr Uptake
Has Been Low In Saudi Arabia Until Now, A Number Of Hospitals Have Implemented Emr Systems
Successfully.
This Paper Analyses Available Studies (N=28) In The Literature Regarding Emr Implantation
In Saudi Arabia To Identify The Progress Of Emr Implementation To Date And To Identify The Facilitators
And Barriers To Implementation

The document and records management is one of the expanding disciplines and organisational functions in the area of information management.  Since we live in digital era, where information is more and more available in electronic form, it is a natural sequence of events that this expertise follows contemporary trends in information world, changing accordingly. It was a long journey from clay tablets to managing electronic records, but what is common in genesis of this profession is one essential requirement for good records management and that is not technology but skilled people...

The key principles of corporate governance include transparency, accountability and risk management. Successful implementation of these principles in public organisations is dependent on the availability of information. In Kenya today many government organisations do not have qualified records professionals and the result is the existence of poor records management that are characterized as fraudulent and corrupt. This paper discusses the role of records management professionals in fighting corruption in Public Sectors of Kenya. The paper argues that qualified Records management professionals are crucial in the fight against corruption because a good records management programme ensures availability of information that can serve as evidence to identify abuse or misuse of resources and noncompliance with legal and regulatory requirements. In addition, good records management practices promote efficiency in the operations of an organisation by eliminating bureaucracies and other loopholes that underpin corruption. Using examples from public sectors in Kenya, this paper attempts to demonstrate the extent to which records management professionals supports the fight against fraud and corruption. The paper also includes literature review that corroborates the examples cited. Recommendations are provided in the conclusion.

Di era globalisasi, banyak masyarakat yang mengerti tentang hak dan kewajiban sebagai masyarakat pengguna pelayanan publik. Tuntutan masyarakat akan pelayanan publik semakin tinggi. Salah satu pelayanan publik dalam bidang kesehatan adalah puskesmas. Sebagai pelayanan kesehatan tingkat pertama, tentunya puskesmas adalah pelayanan kesehatan yang paling dekat dengan masyarakat. Masyarakat dengan mudah menilai pelayanan yang diberikan puskesmas.
Tempat pendaftaran pasien rawat jalan di puskesmas merupakan pelayanan pertama yang diterima oleh masyarakat yang akan beobat atau pasien. Pasien tentunya menuntut supaya pelayanan pendaftaran rawat jalan berkualitas dan dapat memberikan kepuasan. Mengingat pentingnya peningkatan kepuasan pasien maka perlu adanya peningkatan kualitas pelayanan pendaftaran rawat jalan sehingga didapatkan pelayanan yang bermutu sesuai harapan pasien. Oleh karenanya diharapkan dengan telah disepakati kegiatan training petugas pendaftaran rawat jalan ini, maka para unit terkait yang berhubungan dengan rekam medis dapat melaksanakan, memonitor  dan mengevaluasi dengan baik dan terkoordinasi.

En este artículo analizamos algunas cuestiones de la historia clínica cuando se enfoca al ámbito de la salud mental.
En primer lugar, definimos qué es, qué contenido ha de tener y cómo estructurarla. En segundo término, exponemos algunos
principios deontológicos, unos principios éticos y unas virtudes éticas para guiar la elaboración de la HC y el manejo de su
información. En tercero, se examina a quién pertenece y quién puede acceder a la información. Por último, se exponen datos
empíricos sobre la opinión de los pacientes y los profesionales sobre los registros médicos.

1. Indentifikasi dan jelaskan masalah dalam kasus ini! EMR (Electronic Medical Record) menjadi solusi bagi permasalahan dalam bidang perawatan kesehatan. Melihat banyaknya data tertulis di kertas/dokumen yang berisi rekaman medis pesien di rumah sakit, membuat banyak data yang tertulis ganda sehingga sulit diakses dan didistribusikan, ini juga merupakan sebab mengapa biaya perawatan kesehatan sangat tinggi, khususnya di Amerika Serikat. Perancangan EMR merupakan hal yang tidak mudah, dan ini memberikan tantangan bagi layanan medis berskala kecil untuk mengeluarkan biaya dan memenuhi batas waktu yang telah ditentukan untuk memperbaharui system data medis manual ke system data medis electric. Dan ini memberi beban lebih bagi para dokter baik dalam segi tenaga, biaya dan waktu. 2. Faktor Manajemen, organisasi dan teknologi apa saja yang bertanggung jawab terhadap sulitnya membangun system EMR? Jelaskan! 1. Manajamen : Faktor ini bergantung pada pihak pemerintah untuk mengatur kembali bagaimana system electronis Medical Record yang baik dan sesuai dengan standar yang telah ditentukan sesuai dengan visi dari terciptanya system EMR tersebut. 2. Organisasi : Faktor ini dipengaruhi oleh para perawat / karyawan rumah sakit serta dokter dalam optimalisasi penggunaan system EMR tersebut. Sehingga pengaplikasian system EMR dapat digunakan sesui dengan tujuan yaitu mempermudah penyimpanan data dan mempercepat pelayanan.

“Electronic Medical Record (EMR): an electronic sistem automate paper-base medisal record”. Electronic Medical Record  (EMR) atau sering dikenal Rekam medis elektronik, merupakan catatan medis pasien dalam  format  elektronik tentang informasi kesehatan seseorang yang dituliskan oleh satu atau lebih petugas kesehatan secara terpadu. Rekam medis elektronik bisa diakses  dengan komputer atau sistem elektronik dari suatu jaringan, dengan tujuan  utama menyediakan atau meningkatkan perawatan serta pelayanan kesehatan yang efesien  dan terpadu

Clinical decisions are crucial because they are related to human lives. Thus, managers and decision makers in the clinical environment seek new solutions that can support their decisions. A clinical data warehouse (CDW) is an important solution that is used to achieve clinical stakeholders' goals by merging heterogeneous data sources in a central repository and using this repository to find answers related to the strategic clinical domain, thereby supporting clinical decisions. CDW implementation faces numerous obstacles, starting with the data sources and ending with the tools that view the clinical information. This paper presents a systematic overview of purpose of CDWs as well as the characteristics; requirements; data sources; extract, transform and load (ETL) process; security and privacy concerns; design approach; architecture; and challenges and difficulties related to implementing a successful CDW. PubMed and Google Scholar are used to find papers related to CDW. Among the total of 784 papers, only 42 are included in the literature review. These papers are classified based on five perspectives, namely methodology, data, system, ETL tool and purpose, to find insights related to aspects of CDW. This review can contribute answers to questions related to CDW and provide recommendations for implementing a successful CDW.

This capstone action research study focused on nine electronic medical records (EMR) trainers and subject matter experts with no training in instructional design and e-learning tools as e-learning training developers.  The research question addressed in this study is:  "How did the interventional instructional unit impact participants’ attitudes about the ability to use the ADDIE model and incorporate e-learning into electronic medical records system training sessions?"  The study involved an eight hour block of instruction on the ADDIE instructional model and e-learning tools.  The instruments used for data collection were identical pre- and post-surveys.  Data were analyzed and findings made utilizing quantitative analysis.  The study concluded that training in instructional design principles and e-learning tools can improve EMR trainer and subject matter expert knowledge and confidence for developing effective training.

The adoption of Electronic Medical Records (EMR) in healthcare organizations has numerous benefits to physicians, patients, and healthcare services. However, unresolved security and privacy concerns pertaining to patient information cause relatively low adoption of EMR by health institutions. Safeguarding large amount of sensitive health data at different locations and forms proves to be a major challenge of EMR. In this paper, a Systematic Literature Review (SLR) is presented to (1) identify the security and privacy concerns in the adoption of EMR by health organizations and (2) to analyze the existing solutions in addressing the identified concerns. A total of 393 papers were found in this regard. After careful study and the removal of duplicate papers and screening of studies, 15 papers which met the inclusion criteria were selected for the review. This review will help researchers to be aware of the privacy and security concerns of EMR and the existing solutions. The review revealed that the security and privacy issues related to EMR are inadequately addressed. This study indicates that the technical and financial supports are insufficient to overcome the security issues of EMR, and thus, the success factors and security culture should be investigated. Developing countries meet many challenges in adopting EMR, especially due to the lack of security policy and background infrastructure. Hence, novel solutions such as best practice guidelines with respect to security and privacy are necessary to aid successfully adoption EMR.

El uso de sistemas informáticos en el área clínica
permite que los profesionales de la salud manejen mayor
cantidad y variedad de información de forma efectiva y
eficiente, aumentando su capacidad de resolución de
problemas de salud y la calidad asistencial de los pacientes.
Estos son sistemas complejos, difíciles de mantener a largo
plazo, y de costos elevados en su construcción y
mantenimiento, tanto en tiempo como en recursos humanos y
económicos. La falta de aplicación de estándares y buenas
prácticas en su diseño y construcción repercute negativamente en la calidad global del producto final. Esta situación pone en riesgo la viabilidad de los proyectos de informatización del área clínica, a gran escala y largo plazo. En este trabajo planteamos un enfoque distinto en la construcción de sistemas de información en salud, que busca sortear los problemas mencionados, en pos de viabilizar los proyectos de informatización del área clínica en contextos de recursos limitados (económicos y humanos), apuntando a la creación de sistemas informáticos de calidad, basados en estándares, mantenibles a largo plazo y a costos controlados.
Se propone la creación de una herramienta de software para la automatización de tareas en el desarrollo informáticos y un
proceso de desarrollo drásticamente diferente al proceso
actual, donde el profesional de la salud pasa a jugar el rol de
mayor importancia en el proceso, donde el foco está en la
gestión del conocimiento clínico, dejando la tecnología en un
segundo plano. Con el enfoque propuesto se podrían crear
sistemas de registro clínico de gran calidad, en menos tiempo, y con un menor consumo de recursos. Estos sistemas estarían basados en estándares, creados para ser modificados y capaces de evolucionar a largo plazo sin necesidad de modificar el código fuente del software.

Background

We aimed to determine availability of core Hospital Information Systems (HIS) functions implemented in Turkish hospitals and the perceived importance of these functions on quality and patient safety.


Methods

We surveyed quality directors (QDs) at civilian hospitals in the nation of Turkey. Data were collected via web survey using an instrument with 50 items describing core functionality of HIS. We calculated mean availability of each function, mean and median values of perceived impact on quality, and we investigated the relationship between availability and perceived importance.


Results

We received responses from 31% of eligible institutions, representing all major geographic regions of Turkey. Mean availability of 50 HIS functions was 65.6%, ranging from 19.6% to 97.4%. Mean importance score was 7.87 (on a 9-point scale) ranging from 7.13 to 8.41. Functions related to result management (89.3%) and decision support systems (52.2%) had the highest and lowest reported availability respectively. Availability and perceived importance were moderately correlated (r = 0.52).


Conclusion

QDs report high importance of the HIS functions surveyed as they relate to quality and patient safety. Availability and perceived importance of HIS functions are generally correlated, with some interesting exceptions. These findings may inform future investments and guide policy changes within the Turkish healthcare system.

Financial incentives, regulations around certified HIS, revisions to accreditation manuals, and training interventions are all policies which will help integrate HIS functions to support quality and patient safety in Turkish hospitals.

""The existing literature in relation to electronic personal
health records (PHRs) has typically focused on the discussion
of several key issues—namely, their design, functional evaluation, privacy, security and architecture. The benefits of PHRs and barriers preventing their adoption are also widely discussed. These issues are affected by technology infrastructure, and current and
planned technology infrastructure deployment will be key determinants in the selection and design of PHR architectures. Assumptions about the community-wide deployment of required technologies such as hardware and internet accessibility are implicit in the architectural selection of PHRs and these dependencies have not been fully appreciated or addressed in the existing literature. This review article introduces and describes
two infrastructural drivers—ubiquitous technology baseline for PHRs and connectivity coverage—and examines their inter-relationships with the selected PHR architectures. Eleven functional capabilities are also described, providing a basis for the analysis of the relationships between the two infrastructural drivers and architectural selection.""

When most patients visit physicians in a clinic or a hospital, they are asked about their medical history and related medical tests' results which might not exist or might simply have been lost over time. In emergency situations, many patients suffer or sadly die because of lack of pertinent medical information. Patient's Health information (PHI) saved by Electronic Medical Record (EMR) could be accessible only by a hospital using their EMR system. Furthermore, Personal Health Record (PHR) information cannot be solely relied on since it is controlled solely by patients. This paper introduces a novel framework for accessing, sharing, and controlling the medical records for patients and their physicians globally, while patients' PHI are securely stored and their privacy is taken into consideration. Based on the framework, a proof of concept prototype is implemented. Preliminary performance evaluation results indicate the validity and viability of the proposed framework.

Electronic-Prescribing, Computerized Prescribing, or E-RX has increased dramatically of late in the American health care system, a long overdue alternative to the written form for the almost five billion drug treatments annually. This paper examines the history and selected issues in the rise of E-RX by a review of salient literature, interviews, and field observations in Pharmacy. Pharmacies were early adopters of computerization for a variety of factors. The profession in its new corporate forms of chain drug stores and pharmacy benefits firms has sought efficiencies, profit enhancements, and clinical improvements through managed care strategies that rely upon data automation. E-RX seems to be a leading factor in overall physician acceptance of Electronic Medical Records (EMRs), although the Centers for Medicare and Medicaid (CMS) incentives seem to be the propelling force in acceptance. We conclude that greater research should be conducted by public health professionals to focus on resolutions to pharmaceutical use, safety, and cost escalation, which persist and remain dire following health reform.

Objectives: To select best medical informatics research works published in 2013 on electronic health record (EHR) adoption, design, and impact, from the perspective of human factors and organizational issues (HFOI).
Methods: We selected 2,764 papers by querying PubMed (Mesh and TIAB) as well as using a manual search. Papers were evaluated based on pre-defined exclusion and inclusion criteria from their title, keywords, and abstract to select 15 candidate best papers, finally reviewed by 4 external reviewers using a standard evaluation grid.
Results: Five papers were selected as best papers to illustrate how human factors approaches can improve EHR adoption and design. Among other contributions, these works: (i) make use of the observational and analysis methodologies of social and cognitive sciences to understand clinicians’ attitudes towards EHRs, EHR use patterns, and impact on care processes, workflows, information exchange, and coordination of care; (ii) take into account macro- (environmental) and meso- (organizational) level factors to analyze EHR adoption or lack thereof; (iii) highlight the need for qualitative studies to analyze the unexpected side effects of EHRs on cognitive and work processes as well as the persistent use of paper.
Conclusion: Selected papers tend to demonstrate that HFOI approaches and methodologies are essential to bridge the gap between EHR systems and end users, and to reduce regularly reported adoption failures and unexpected consequences.

Development of information and communication technology (ICT) has made it possible to use electronic medical records (EMR) for more than record keeping but also to enable the storage, collection, sharing, and management of EMR among healthcare personnel and other related healthcare institutions. The rapid development of Internet-based computing allows numerous technologies to be developed and this come with the risk of information getting to the hand of cyber criminals for various criminal acts, hence this study was informed. Access control and security of computer-based technology provides solution to this problem in health sector in particular. The system was developed using PHP as the backend, HTML and CSS as the frontend, apache as the server and mysql as the database. The proposed designed reduced patients" information access rate and enhance information integrity through encryption of patient information that is stored in the EMR, so that the data can be accessed only by authorized persons having secured the approval from the concerned patient(s).

Patient information recorded in electronic medical records is the most significant set of information of the healthcare system. It assists healthcare providers to introduce high quality care for patients. The aim of this study identifies the security threats associated with electronic medical records and gives recommendations to keep them more secured. The study applied the qualitative research method through a case study. The study conducted seven interviews with medical staff and information technology technicians. The study results classified the issues that face electronic medical records into four main categories which were availability, accessibility, privacy, and safety of health information.

Rumah Sakit Paru jember merupakan salah satu rumah sakit yang menerapkan billing  system  untuk membantu  dalam proses pembiayaan pasien rawat inap. Penilaian teknologi diperlukan untuk menilai seberapa besarkah kontribusi    teknologi  yang  dimiliki  oleh suatu  teknologi  tertentu  dalam_ suatu  sistem  pembiayaan  pasien rawat inap.  Penilaian  teknologi  ini menggunakan  metode Teknometrik  dan Simple  Multi  Attribute    Rating (SMART).  Tujuan  dalam penelitian  ini, yaitu: Melakukan  identifikasi  dan penilaian  teknologi
SisremInformasi  Manajemen Rumah Sakit Pam Iember dengan Teknometrik dan SMART. Hasil penelitian ini
pm: Kemampuan  dan Kandungan teknologi Sistem informasi manajemen rumah sakit (billing  system)  rawat inap adalah:    Komponen  Technoware  sebesar 0,632; Komponen Humanware    sebesar 0.593; dan Komponen
Infuware  sebesar 0,524 dan Orgaware  sebesar 0,579. Kontribusi  tersebut  dapat  diurutkan  sebagai  berikut: T>  H  > 0  > I. Sedangkan koefisien kandungan teknologi yang dihasilkan adalah 0.577. Dapat disimpulkan hahwa  teknologi  sistem informasi  manajemen  rumah  sakit rawat inap di Rumah  Sakit Pam  Iember  yang meroiJiki nilai Tcc  = 0,577 termasuk  dalam klasifikasi semi modem  (0,3 < Tcc  0,7). Saran yang dapat
diberikan  pada pihak rumah sakit adalah meningkatkan  kualitas aplikasi dari sistem informasi  manajemen Rumah  sakit rawat inap, khususnya pada komponen infoware  (peragkat informasi) dengan memberikan  menu  tambahan yang  disesuaikan  dengan rekam medik rawat inap secara manual.                                                       
:Kata kunci:  Penilaian Teknologi, Teknometrik, SMART, SIMRS Rawat Inap

Healthcare Information Systems are a big business. Currently there is an explosion of EHR/EMR products available on the market, and the best tools are really expensive. Many developing countries and healthcare providers cannot access such tools, and for those who can, there is not a clear strategy for the evolution, scaling, and cost of these electronic health products. The lack of standard-based implementations conduct to the creation of isolated information silos that cannot be exploited (i.e. shared between providers to promote a holistic view of each patient's medical history). This paper exposes the main elements behind a Standard-based Open Source EHR Platform that is future-proof and allows to evolve and scale with minimal cost. The proposed EHR Architecture is based on openEHR specifications, adding elements emerged from research and development experiences, leading to a design that can be implemented in any modern technology. Different implementations will be interoperable by design. This Platform will leverage contexts of scarce resources, reusing clinical knowledge, a common set of software components and services.

This research focuses on the modern HMIS' ability to improve the operational efficiency of health-care facilities, generation, and use of medical data for the benefit of its citizens and stakeholders, electronic record-keeping, and the ability to share the data across various systems. Such a system will involve blockchain transactions and the immutable tracking of services extended. In the proposed configuration, the modern HMIS is built to allow data consolidation and improve health-care services and clinical research. The use of data analytics will reduce errors and improve clinical decision making and universal access to critical medical information in real time. Flexibility and the ability to interface and integrate to other systems will play a crucial role in data access and ultimately the cornerstone of an efficient medical record- keeping system. Such a system not only manages the clinical information but it will also manage pharmacy supplies, efficiently dispatch hospital services such as nurse management of the patient, bed transfers, radiography, consultation tracking which will all be integrated into the HMIS modules with real-time visibility via a shared dashboard.

FEMI is a federation of 23 private not-for-profit providers across Uruguay. It covers approximately 700 thousand people and owns a tertiary center in Montevideo. Pressure from ongoing national changes in health funding and regulation have pushed FEMI to develop a project, in order to improve efficiency in health care through the use of information and communications technologies. In particular, a federal electronic health record and a strategic management system are pursued. This project is supported by the Inter American Development Bank. The project has four lines of action: Specification, construction and implementation of the systems; Alignment through the use of standards; Cultural change through training and prototype systems; and Infrastructure. Short term results include a federal balanced scorecard, federal identification and authorization services, a terminology service, telemedicine applications and massive training of interdisciplinary teams at the local level. The importance of collaboration at the regional level and the advantages of having a multi-institutional commitment are stressed.

Purpose: The purpose of this research is three-fold. The first purpose is to establish a practical ideal model of Electronic Health Records (E.H.Rs) used in hospitals by reviewing relevant scholarly literature. The second purpose is to assess the extent Central Texas Medical Center (C.T.M.C) in San Marcos, Texas adheres to the elements of the ideal model. The final purpose is to provide recommendations for improving the current E.H.R system used at C.T.M.C. A thorough review of the literature identified eight key components of Electronic Health Records based on the Institute of Medicine Report, Key Capabilities of an Electronic Health Record, 2003. The components include: Health Information and Data, Results Management, Order Entry/Management, Decision Support, Electronic Communication and Connectivity, Patient Support, Administrative Processes, and Reporting and Population Health Management.
Methodology: The components of an Electronic Health Record identified in the literature led to the development of the conceptual framework. The conceptual framework was the assessment tool used to gauge the Electronic Health Record (E.H.R) system used at Central Texas Medical Center (C.T.M.C). The methodology used to collect data and make assessments was structured interviews and direct observation.
Findings: Structured interviews and direct observation revealed the E.H.R system used at C.T.M.C met all or the majority of components for Health Information and Data, Results Management, Order/Entry Management, and Patient Support. Components that were missing included reminders for preventive services for patients, epidemiologic data and automated real time surveillance in Decision Support, patient to provider communication and medical record integration across settings in Electronic Communication and Connectivity, clinical trial, drug recall and chronic disease management in eligibility determination in Administrative Processes.

K Albuquerque, Alexis Andrew Miller, J Roeske

The quality of any medical treatment depends upon the accurate processing of multiple complex components of information with proper delivery to the right patient. This is true for radiation oncology where treatment delivery is as complex as a surgical procedure but more dependent on hardware and software technology. Uncorrected errors, whether small or infrequent, can and have resulted in catastrophic consequences for the patient.

In an attempt to reduce errors, we have implemented and developed the use of checklists within the oncology EMR. These checklists enable the processing, confirmation, and documentation of relevant patient information prior to the accurate delivery of radiation treatment. The checklist as we have implemented, will pick up many potentially correctable errors and ensure safe and accurate delivery of radiation treatments. We describe our successes and limitations with our electronic checklists (ECL) in this article.