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The utility for audit of manual and computerized problem-oriented medical record systems
Health Services Research
|January 1, 1982
Summary
Physicians found no difference in reliability between manual Problem-Oriented Medical Records (POMR) and computerized PROMIS for auditing care. PROMIS offered more thorough information, while manual POMR was preferred for conciseness and organization.
Area of Science:
- Medical Informatics
- Healthcare Management
- Clinical Documentation
Background:
- Objective assessment of healthcare delivery relies on clear records of events and decisions.
- Both manual Problem-Oriented Medical Records (POMR) and computerized Problem Oriented Medical Information Systems (PROMIS) aim to facilitate care audits.
Purpose of the Study:
- To compare the effectiveness of manual POMR and PROMIS in serving the function of audit.
- To gather physician perspectives on which record system is superior for auditing care delivery.
Main Methods:
- A national sample of physicians evaluated 69 matched pairs of patient records.
- Records were drawn from two ward settings: one using manual POMR, the other using PROMIS.
- Physicians assessed reliability, analytical reasoning, thoroughness, conciseness, accessibility, and organization.
Main Results:
- No significant difference was found between POMR and PROMIS regarding information reliability or provider analytical reasoning.
- PROMIS records were perceived as slightly more thorough in their information content.
- The manual POMR format was rated higher for conciseness, accessibility, and overall organization.
Conclusions:
- Both POMR and PROMIS have strengths and weaknesses for care audit purposes.
- Manual POMR excels in user-friendly organization and conciseness, while PROMIS offers greater data thoroughness.
- Further research may explore hybrid systems or improvements to enhance audit capabilities in electronic health records.