Electronic Records in the Medical World

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TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION1

Background1

Theoretical framework1

Significance of the Study2

Statement of the problem2

Rationale of the study3

Research questions3

Approach for completing literature4

CHAPTER 2: LITERATURE REVIEW5

Collective organizational efforts6

History of the Electronic Health Record8

Literary relationship of recent studies to the EMR9

New technology12

The proliferation of hospital health IT and electronic medical records14

Technology Acceptance and TAM14

Technology Acceptance in Industry16

Clinical Documentation17

Redundancy18

Text duplication without redundancy18

Clinical Summarization19

Information Duplication in Clinical Notes20

Technology Acceptance in Healthcare20

Summary22

REFERENCES24

ANNOTATED BIBLIOGRAPHY28

CHAPTER 1: INTRODUCTION

Background

The healthcare industry traditionally has been an industry in which service provider- to-patient communication was conducted in a protective, encrypted language, in which a provider wrote notes in Latin shorthand and used terminology so that a patient could not understand the diagnosis, problem, or process. Thompson (2007) writes, when the doctor handed the patient a prescription, it was written in Latin to prevent communication. Patients believed the physician's instructions and diagnosis could not be challenged or scrutinized (Thompson, 2007).

Theoretical framework

Healthcare professionals did not want to be challenged or receive criticism for their work. Thompson (2007) points out, the concern that the public will not understand and will be misled is certainly legitimate, but it is sometimes expressed a covert means of protecting the guild, rather than the public. There is valuable equity in the concentration of information. Benjamin Spock's self-help articles and books were the first indication of change, spurring healthcare industry players to write more accessible, understandable articles and books on various healthcare issues. Various industries' integration of computers from the 1950s onward finally began in the healthcare industry (Thompson, 2007).

In order to ease the burden of electronic note entry on physicians, electronic documentation support (EDS) tools have been developed to assist in note authoring. EDS includes tools that facilitate the reuse of existing text, the automatic generation of text to be inserted into notes, and the structuring of notes.

Significance of the Study

This project was undertaken as an attempt to contribute to research in the field of health care management. As mentioned previously in the literature, the role of technology in the health care industry is being given much attention due to the fact that speedy, effective and efficient service is crucial in that industry. Hence, the study attempted to provide stakeholders, namely, physicians, nurses, health care administrators, clinicians and others involved in the field with information that would assist them to evaluate the use of technology in health care record-keeping in their own institution (An, 2006).

Statement of the problem

The use of electronic documentation can improve the availability and legibility of clinical information", as well as enable the use of automated decision support and data analysis tools. Furthermore, studies suggest electronic notes are more complete and relevant to patient care than paper records", and that they reduce healthcare costs'. While the digitization of medical records has been shown to be beneficial by several measures", many EHRs are isomorphic transformations of the paper charts they replace. One of the desired results of the digitization of clinical information has been the increased quantity of data available to ...