Design, Development, Implementation and Evaluation of Electronic Medical Record in Shahid Madani Hospital of Tabriz University of Medical Sciences

Abstract

Abstract Background: To develop and sustain their activities, health care organizations seek to improve the quality of services and improve processes, and this will only be possible through timely access to quality information. In this regard, paper files are unable to meet the needs of organizations due to their limitations. Therefore, to solve this problem, it is necessary to obtain electronic medical records. Objective: This study was conducted with the aim of design, development, implementation and evaluation of electronic medical records in Shahid Madani Hospital of Tabriz University of Medical Sciences. Method and Material: First, the current status of Shahid Madani Hospital was evaluated from the point of view of electronic clinical documentation processes and medical records using a checklist made by the researcher. Then, the information requirements and data elements of electronic medical record modules were determined based on systematic reviwe and expert panel and confirmed by Delphi method. In the next step, electronic medical record was developed based on the determined framework in the previous phases. After the implementation of the system in July and August 2023, the system was evaluated based on time indicators, quality of medical documentation and user experience. Results: The evaluation of the current situation of Shahid Madani Hospital showed that most clinical documentation processes are traditional and paper-based. 1479 data elements were identified and confirmed based on systematic review, expert panel and Delphi technique. A total of 351 medical records were used to evaluate the system. Due to the implementation of the system, the average clinical documentation time of each case decreased by 75 minutes, and the quality of clinical documentation increased from 79.99% to 100%. The average score of users' satisfaction with the system was 4.64 out of 5. Conclusion: The findings of the study showed that with the development and use of the relevant system, the time of clinical documentation has been significantly reduced and the quality of documentation has also increased. Also, user satisfaction with the system has been significantly high. Therefore, the use of electronic medical records in Shahid Madani Hospital of Tabriz can lead to the improvement of health processes and the improvement of the quality of medical services. Key words: Health Information, Electronic Medical Records, Healthcare Organizations, Interoperability