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ABSTRACT OF SCIENTIFIC PAPER
TITLE : (ELECTRONIC MEDICAL RECORD)
To study EMR Status in AIIMS
AUTHOR :
R.K.Kaul, Jr. MRO – JPNATC
Medical Record Technicians –JPNATC
Dr. S.K.Bhoi (Faculty In-Charge MRS )
EMR: Electronic Medical Record, it is a systematic,
sequential and chronological ordered patient’s health
information in electronic form, in a given time frame, in any
healthcare centre.
EMR systems are designed to store, retrieve, transfer,
share data safely, efficiently and accurately at low cost
maintenances.
EMR can improve the efficiency and quality of medical care
and can minimize the repetition of work done.
EMR will help in reducing a bit in Carbon Emission into
atmosphere; consequently; will put affect on reducing
Global Warming.
Introduction:
AIM:
To introspection the progress achieved
in MRD, in developing and transforming,
medical record documents
Into Digital/computerized Form
within AIIMS.
Prepare desired questionnaire which contains
30 essential MRD documents related to patient
care. The said questionnaire was floated among
all MRD sections of AIIMS and collected
information.
Questionnaire Prepared is as:
METHODOLOGY:
SL. No.
Documents
In electronic format
Yes (Y) No (N)
1 Casualty Registration Slip
2 Face Sheet
3 Discharge Summary
4 Death Summary
5 OPD Card
6 MLC Report
7 Casualty Note
8 Clinical Notes
9 Nursing Chart
10 Nursing Daily Record
11 Patient information Aadhar Card link
12 Investigation Report
13 Operation Record
14 Consultation Record
15 Consent Form
16 Anaesthesia Record
17 PET Scan Film
18 PET Scan Report
19 CT Scan Report
20 USG Report
21 MRI Film
22 MRI Report
23 Paediatrics Immunization Record
24 Drug Distribution Record
25 In – Patient information Display unit
26 Online Patient OPD Registration
27 Histopathology Report
28 Death Record
29 Birth Record
30 PM Report
Name of Centre :____________________________________________________________________
Date of Data collection :________________________________________________________________
Name of Data collector:_____________________________________________(Sign )_______________
Title of study :EMR status in AIIMS
Total Bed Strength in centre :___________________________OPD Data Total (2014-2015)
Total In-Patient Admission in centre :_____________________ Male +Female = Total Patient
To
MRO
M.R. Department
Kindly issue the following information to the bearer
(Dr. S.K.Bhoi )
Principal Investigator (R. K. Kaul)
Investigator
Statistical Methods, tool, tests and techniques
are involved in this Sample study
• Various Statistical tool, tests of Significances
and techniques are involved in this study:
Sample questionnaire prepared, Census
collection Method adopted, Bar-Chart, Pia-
chart, Pearson’s K2 test, Simple Average,
Percentage, Used Primary Data, various
references and Help books used,... etc
The work done/ initiated is indicated by symbol “Y” and
work not done /not initiated is indicated as symbol “N”.
The range of digitalization of documents is set as:
(Documents in digital Form)
Where:
Y = /26 ~ 30 → Access through Internet application/s to AIIMS Medical record Documents
Y= / 21 ~ 25 → Full Digitalization
Y= /16 ~ 20 → Semi-Digitalization
Y= /11 ~ 15 → Progress :Achieved
Y= /06 ~ 10 → Progress :under Process
Y= /01 ~ 05 → Initiated
y= / ~00 → Not Initiated
RESULT: Contd./
The Centre wise statistics is indicated below:
Sr. No. Name of Super Speciality
Centre
No. of doc.
Indicating
“Y’’
No. of doc. Indicating
“N’’
Total No. of
document
% of digitalization
/ computerization
Result
1. JPNATC 20 10 30 67% Semi-Digitalized
2. AIIMS Hospital (Main) 18 12 30 60% Semi-Digitalized
3. IRCH 08 22 30 27% Progress: U/Process
4. RPC 08 22 30 27% Progress: U/Process
5. NSC (OPD BASE) 05 25 30 17% Initiated
6. CTC (OPD BASE) 05 25 30 17% Initiated
7. CDER 01 29 30 3% Initiated
8. NDDTC (GBZ.) 01 29 30 3% Initiated
9. CRHS (Ballabgarh.) 03 27 30 10% Initiated
10. OUT-REACH OPD
(Jhajjar HR)
Over all AIIMS
performance
02
73
28
227
30
300
6%
24%
Initiated
Progress :under
Process
Centre-wise (Digital Form
Medical Record documents) (Y)
0
5
10
15
20
25
Series 1
Centre-wise (in Digital Form Medical
Record Documents) (Y) Contd/-
0
0.5
1
1.5
2
2.5
3
3.5
CDER NDDTC CRHS OUT- REACH
OPD
Series 1
%age of Medical Record Documents
Centre-wise in Digital Form i/r/t Whole
AIIMS
24%
21.60%
9.60%
9.60%
6%
6%
1.20%
1.20% 3.60% 2.40%
JPNATC- 24%
HOSPITAL MAIN- 21.60%
IRCH- 9.60%
RPC- 9.60%
NSC- 6%
CTC- 6%
CDER -1.20%
NDDTC -1.20%
CRHS- 3.60%
OUT-REACH OPD- 2.40%
%age of Medical Record Documents
Centre-wise in Digital Form i/r/t Whole
AIIMS
24%
21.60%
9.60%
9.60%
6%
6%
1.20%
1.20% 3.60% 2.40%
JPNATC
HOSPITAL MAIN
IRCH
RPC
NSC
CTC
CDER
NDDTC
CRHS
OUT -REACHED OPD
Results:
• Medical record documents of patients need to be computerized
/digitalized for the safety, Security, future planning of treatment,
research purposes, drug trial purpose and hospital expansion
purposes, Hospital industry developing purposes, etc…
• It also becomes essential for every healthcare centre nowadays,
to store data in Electronic Form, for hospital safety and patient
health information purposes. It can be stored and retrieve at a very
low cost maintenance.
• It can also reduce a bit Carbon Emission into atmosphere,
consequently, will put affect on reducing Global Warming.
DISCUSSION:
During the course of study, it was seen that the
information collected from MRD offices was bit difficult
to collect.
Because of the fact, such a survey was conducted First
time in AIIMS by MRS and the MRD staff concerned feel
reluctant to reply the questions asked by enumerator.
Besides this fact, some Super speciality Centres did not
provide information in time. Like NDDTC, OUT-REACH
OPD, CRHS,CDER. They took too much time to reply,
than rest of Centres, like JPNATC, NSC, CTC, RPC, IRCH and
Hospital (Main) submit their respective reports in due
course of time.
CONCLUSION:
Many efforts had been taken by AIIMS authority
in past, to digitalize medical record . It had proven good
results, This study reflects that AIIMS had initiated the
process of Digitalizing patients health information. At
the same time, there are many areas, where the process
of digitization is pending. Such areas have identified
through this Study; and need to transform paper
document into Digital Form for Hospital improvement
and for smooth functioning and showing High level of
patient care delivery system in AIIMS.
(The comprehensive report of this scientific paper o can be seen in JPNATC website at MRS portal after due web reconstruction)
THANK YOU
From
Medical recordsection-Team
JPNATC

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scientific paper on emr

  • 1. ABSTRACT OF SCIENTIFIC PAPER TITLE : (ELECTRONIC MEDICAL RECORD) To study EMR Status in AIIMS AUTHOR : R.K.Kaul, Jr. MRO – JPNATC Medical Record Technicians –JPNATC Dr. S.K.Bhoi (Faculty In-Charge MRS )
  • 2. EMR: Electronic Medical Record, it is a systematic, sequential and chronological ordered patient’s health information in electronic form, in a given time frame, in any healthcare centre. EMR systems are designed to store, retrieve, transfer, share data safely, efficiently and accurately at low cost maintenances. EMR can improve the efficiency and quality of medical care and can minimize the repetition of work done. EMR will help in reducing a bit in Carbon Emission into atmosphere; consequently; will put affect on reducing Global Warming. Introduction:
  • 3. AIM: To introspection the progress achieved in MRD, in developing and transforming, medical record documents Into Digital/computerized Form within AIIMS.
  • 4. Prepare desired questionnaire which contains 30 essential MRD documents related to patient care. The said questionnaire was floated among all MRD sections of AIIMS and collected information. Questionnaire Prepared is as: METHODOLOGY:
  • 5. SL. No. Documents In electronic format Yes (Y) No (N) 1 Casualty Registration Slip 2 Face Sheet 3 Discharge Summary 4 Death Summary 5 OPD Card 6 MLC Report 7 Casualty Note 8 Clinical Notes 9 Nursing Chart 10 Nursing Daily Record 11 Patient information Aadhar Card link 12 Investigation Report 13 Operation Record 14 Consultation Record 15 Consent Form 16 Anaesthesia Record 17 PET Scan Film 18 PET Scan Report 19 CT Scan Report 20 USG Report 21 MRI Film 22 MRI Report 23 Paediatrics Immunization Record 24 Drug Distribution Record 25 In – Patient information Display unit 26 Online Patient OPD Registration 27 Histopathology Report 28 Death Record 29 Birth Record 30 PM Report Name of Centre :____________________________________________________________________ Date of Data collection :________________________________________________________________ Name of Data collector:_____________________________________________(Sign )_______________ Title of study :EMR status in AIIMS Total Bed Strength in centre :___________________________OPD Data Total (2014-2015) Total In-Patient Admission in centre :_____________________ Male +Female = Total Patient To MRO M.R. Department Kindly issue the following information to the bearer (Dr. S.K.Bhoi ) Principal Investigator (R. K. Kaul) Investigator
  • 6. Statistical Methods, tool, tests and techniques are involved in this Sample study • Various Statistical tool, tests of Significances and techniques are involved in this study: Sample questionnaire prepared, Census collection Method adopted, Bar-Chart, Pia- chart, Pearson’s K2 test, Simple Average, Percentage, Used Primary Data, various references and Help books used,... etc
  • 7. The work done/ initiated is indicated by symbol “Y” and work not done /not initiated is indicated as symbol “N”. The range of digitalization of documents is set as: (Documents in digital Form) Where: Y = /26 ~ 30 → Access through Internet application/s to AIIMS Medical record Documents Y= / 21 ~ 25 → Full Digitalization Y= /16 ~ 20 → Semi-Digitalization Y= /11 ~ 15 → Progress :Achieved Y= /06 ~ 10 → Progress :under Process Y= /01 ~ 05 → Initiated y= / ~00 → Not Initiated
  • 8. RESULT: Contd./ The Centre wise statistics is indicated below: Sr. No. Name of Super Speciality Centre No. of doc. Indicating “Y’’ No. of doc. Indicating “N’’ Total No. of document % of digitalization / computerization Result 1. JPNATC 20 10 30 67% Semi-Digitalized 2. AIIMS Hospital (Main) 18 12 30 60% Semi-Digitalized 3. IRCH 08 22 30 27% Progress: U/Process 4. RPC 08 22 30 27% Progress: U/Process 5. NSC (OPD BASE) 05 25 30 17% Initiated 6. CTC (OPD BASE) 05 25 30 17% Initiated 7. CDER 01 29 30 3% Initiated 8. NDDTC (GBZ.) 01 29 30 3% Initiated 9. CRHS (Ballabgarh.) 03 27 30 10% Initiated 10. OUT-REACH OPD (Jhajjar HR) Over all AIIMS performance 02 73 28 227 30 300 6% 24% Initiated Progress :under Process
  • 9. Centre-wise (Digital Form Medical Record documents) (Y) 0 5 10 15 20 25 Series 1
  • 10. Centre-wise (in Digital Form Medical Record Documents) (Y) Contd/- 0 0.5 1 1.5 2 2.5 3 3.5 CDER NDDTC CRHS OUT- REACH OPD Series 1
  • 11. %age of Medical Record Documents Centre-wise in Digital Form i/r/t Whole AIIMS 24% 21.60% 9.60% 9.60% 6% 6% 1.20% 1.20% 3.60% 2.40% JPNATC- 24% HOSPITAL MAIN- 21.60% IRCH- 9.60% RPC- 9.60% NSC- 6% CTC- 6% CDER -1.20% NDDTC -1.20% CRHS- 3.60% OUT-REACH OPD- 2.40%
  • 12. %age of Medical Record Documents Centre-wise in Digital Form i/r/t Whole AIIMS 24% 21.60% 9.60% 9.60% 6% 6% 1.20% 1.20% 3.60% 2.40% JPNATC HOSPITAL MAIN IRCH RPC NSC CTC CDER NDDTC CRHS OUT -REACHED OPD
  • 13. Results: • Medical record documents of patients need to be computerized /digitalized for the safety, Security, future planning of treatment, research purposes, drug trial purpose and hospital expansion purposes, Hospital industry developing purposes, etc… • It also becomes essential for every healthcare centre nowadays, to store data in Electronic Form, for hospital safety and patient health information purposes. It can be stored and retrieve at a very low cost maintenance. • It can also reduce a bit Carbon Emission into atmosphere, consequently, will put affect on reducing Global Warming.
  • 14. DISCUSSION: During the course of study, it was seen that the information collected from MRD offices was bit difficult to collect. Because of the fact, such a survey was conducted First time in AIIMS by MRS and the MRD staff concerned feel reluctant to reply the questions asked by enumerator. Besides this fact, some Super speciality Centres did not provide information in time. Like NDDTC, OUT-REACH OPD, CRHS,CDER. They took too much time to reply, than rest of Centres, like JPNATC, NSC, CTC, RPC, IRCH and Hospital (Main) submit their respective reports in due course of time.
  • 15. CONCLUSION: Many efforts had been taken by AIIMS authority in past, to digitalize medical record . It had proven good results, This study reflects that AIIMS had initiated the process of Digitalizing patients health information. At the same time, there are many areas, where the process of digitization is pending. Such areas have identified through this Study; and need to transform paper document into Digital Form for Hospital improvement and for smooth functioning and showing High level of patient care delivery system in AIIMS. (The comprehensive report of this scientific paper o can be seen in JPNATC website at MRS portal after due web reconstruction)