Evaluation of a computerized problem-oriented medical record in a hospital department: Does it support daily clinical practice?

摘要

Purpose: Evaluation of a computerized problem-oriented medical record (CPOMR) for health care work.rnMethods: A qualitative study of the daily use of a CPOMR at an internal medicine hospital ward over a period of 3 months, during which 66 patients were treated based on clinical information recorded in the CPOMR though back up by a paper-based record was available. The study is based on participant observation and interviews with the clinicians who had the most profound and extensive experience in the use of the CPOMR. Before and during the test-period the author attended project planning meetings, a training workshop in the use of the CPOMR for nurses and physicians and local coordination meetings. After the test, one focus-group discussion with physicians and nurses (6 participants; duration 11/2 h) was conducted as well as 13 open-ended interviews (5 nurses, 2 social and health assistants, 4 physicians, 2 IT-people; duration: 16-42 min; average of 29 min). The interviewees formed the core group using the CPOMR.rnResults: Use of the CPOMR led to more time spent documenting clinical work, fragmentation of patient situation into separate problems, and lack of an overview.rnConclusion: The problem-oriented method for structuring a computerized medical record may provide a description of how physicians think or ought to think, but does not adequately support complex clinical work. While the CPOMR can be used for patients with few, simple problems who are admitted for only a short time, it is not useful for patients with a complex set of problems or for patients admitted for longer periods of time. This is in accordance with criticism of the paper-based POMR, the problematic points of which do not seem to be alleviated through computerization. The problem-oriented way of ordering information should be accompanied by a source- and time-oriented approach.