TY - JOUR
T1 - Effect of implementation of a coded problem list entry subsystem
AU - Chen, Chia Chang
AU - Chang, Chung Hsin
AU - Peng, Yen Chun
AU - Poon, Sek Kwong
AU - Huang, Shih Che
AU - Li, Yu Chuan Jack
N1 - Publisher Copyright:
© 2016
PY - 2016/10/1
Y1 - 2016/10/1
N2 - Objectives Complete patient problem lists may improve the quality of care. To improve the completeness of the lists at our institution, we implemented the coded problem list entry subsystem (CPLES) in our electronic medical record system. Subsequently, physicians used the CPLES instead of handwritten notes to document coded problem lists and progress notes. We evaluated the effect of implementing the CPLES on the completeness of problem lists. Methods We compared the completeness of coded problem lists input after CPLES implementation with that of problem lists handwritten before CPLES implementation and determined the differences. Moreover, the efficiency and usability of the CPLES were evaluated. Results The efficiency and usability of CPLES were acceptable. However, the completeness of problem lists was reduced after CPLES implementation. The possible reasons for this reduction, namely system usability, efficacy, incentives, leadership, and education, were crucial for successful CPLES implementation and are discussed in the text. Conclusion CPLES implementation reduced the completeness of problem lists. Institutions may learn from our experience and carefully implement their own coded problem list systems to avoid this consequence.
AB - Objectives Complete patient problem lists may improve the quality of care. To improve the completeness of the lists at our institution, we implemented the coded problem list entry subsystem (CPLES) in our electronic medical record system. Subsequently, physicians used the CPLES instead of handwritten notes to document coded problem lists and progress notes. We evaluated the effect of implementing the CPLES on the completeness of problem lists. Methods We compared the completeness of coded problem lists input after CPLES implementation with that of problem lists handwritten before CPLES implementation and determined the differences. Moreover, the efficiency and usability of the CPLES were evaluated. Results The efficiency and usability of CPLES were acceptable. However, the completeness of problem lists was reduced after CPLES implementation. The possible reasons for this reduction, namely system usability, efficacy, incentives, leadership, and education, were crucial for successful CPLES implementation and are discussed in the text. Conclusion CPLES implementation reduced the completeness of problem lists. Institutions may learn from our experience and carefully implement their own coded problem list systems to avoid this consequence.
KW - Electronic medical record
KW - Meaningful uses
KW - Problem oriented medical records
KW - SNOMED CT
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U2 - 10.1016/j.cmpb.2016.05.012
DO - 10.1016/j.cmpb.2016.05.012
M3 - Article
C2 - 27480728
AN - SCOPUS:84975885775
SN - 0169-2607
VL - 134
SP - 1
EP - 9
JO - Computer Methods and Programs in Biomedicine
JF - Computer Methods and Programs in Biomedicine
ER -