Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS). This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians.
Aust-Agder Hospital is the first hospital in Norway to eliminate the paper-based medical record, using a widespread and commercially available HIS in combination with scanning technology. In a recent report, we have evaluated the EMR part of the HIS in this hospital, discussing the views of the physicians only. However, to get a more complete picture of the impact of the system, its use by employees other than physicians needs to be evaluated. Both medical secretaries and nurses are important users of a HIS, utilizing both the EMR and the administrative part of the system. The medical secretaries work as transcriptionists, receptionists and coordinators of patient logistics and communication, and the nurses have their own documentation and administrative routines. The elimination of the paper-based medical records is a radical change in the work routines in the hospital organization. To assess the impact of this change on the organization, the EMR system may be described from the perspectives of three important employee groups separately. In this report, we have used questionnaires and interviews to assess how often medical secretaries, nurses and physicians use the HIS system for essential tasks, how easily these tasks are performed using the system, and how satisfied the hospital employees are with it.
The medical secretaries use the HIS much more than the nurses and the physicians, and they consider that the electronic HIS greatly has simplified their work. The work of nurses and physicians has also become simplified, but they find less satisfaction with the system, particularly with the use of scanned document images.
Conclusions
Although the basis for reference is limited, the results support the assertion that replacing the paper-based medical record primarily benefits the medical secretaries, and to a lesser degree the nurses and the physicians. The varying results in the different employee groups emphasize the need for a multidisciplinary approach when evaluating a HIS.
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