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Effect of implementation of a coded problem list entry subsystem.

Chia-Chang Chen¹, Chung-Hsin Chang², Yen-Chun Peng³

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; College of Medicine Science and Technology, Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan.

Computer Methods and Programs in Biomedicine

|August 3, 2016

Summary

This summary is machine-generated.

Implementing a coded problem list entry subsystem (CPLES) in electronic medical records did not improve patient problem list completeness. Careful consideration of system usability and other factors is crucial for successful implementation.

Keywords:

Electronic medical record Meaningful uses Problem oriented medical records SNOMED CT

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Area of Science:

Health Informatics
Medical Record Systems
Quality Improvement

Background:

Complete patient problem lists are essential for quality healthcare.
Electronic medical record (EMR) systems offer potential for improving problem list documentation.
The coded problem list entry subsystem (CPLES) was introduced to enhance problem list completeness.

Purpose of the Study:

To evaluate the impact of implementing the CPLES on the completeness of patient problem lists.
To assess the efficiency and usability of the CPLES.

Main Methods:

A comparative analysis of problem list completeness before and after CPLES implementation.
Evaluation of CPLES efficiency and usability through physician feedback.

Main Results:

CPLES demonstrated acceptable efficiency and usability.
Problem list completeness significantly decreased following CPLES implementation.
Factors such as system usability, efficacy, incentives, leadership, and education influenced the outcome.

Conclusions:

CPLES implementation led to a reduction in problem list completeness.
Healthcare institutions should carefully plan and implement coded problem list systems, considering potential pitfalls.
Lessons learned from this experience can guide future EMR system integrations for improved patient care quality.