Gibby G L, Schwab W K
Department of Anesthesiology, University of Florida, Gainesville 32610-0254, USA.
J Clin Monit Comput. 1998 Aug;14(6):385-91. doi: 10.1023/a:1009971521520.
Despite efforts to develop electronic access to medical records, there are few data on availability of past evaluations. Typical analyses assess only availability of paper charts. We studied the availability of prior internal and external medical documentation in the preanesthetic clinic of our tertiary teaching institution, which has had access to hospital-wide electronic records for five years.
Residents and clerks answered questions on availability of desired pre-existing records either in a physical chart delivered to our clinic by computer terminal, at the start of the physician interview, and on later success in obtaining desired records not available at start of interview. Patient interview lengths were calculated.
397 responses from 19-9-96 through 25-10-96 were available after 718 patient encounters. The surgeon's history & physical was unavailable in 11%. For 114/397 patients (29%) the anesthesiologist desired more preexisting information than was available in either paper or electronic format. For 32/397 patients (8%), the desired information resided outside the institution ("MISSING EXTERNAL"); for 89/397 (22%), it was within the institution ("MISSING INTERNAL"). Additional information was desired for 41% of ASA 3/4 patients, and for 23% of ASA 1/2 patients. Some or all of desired information was not found for 45% of MISSING INTERNAL, and for 78% (p = 0.12 NS) of MISSING EXTERNAL. MISSING EXTERNAL of any ASA status required significantly longer evaluations (70+/-39 min) than even ASA 3/4 patients missing no information (51.4+/-35.7 min, p 0.03). The surgeries of only eight patients (2%) were postponed in the preanesthetic evaluation clinic; half of the postponements were to obtain pre-existing records.
Anesthesiologists retrieved, and added to the perioperative evaluation, information from previous encounters for 16% of patients. Despite our hospital-wide electronic records, internal information was missing for 22% of patients. Uneven deployment, and reliance on transcription may contribute to failures. A national electronic medical records system would benefit the 8% (one out of twelve) of outpatients missing external records identified in this study. For many patients, optimal medical understanding was not achieved during the planned preanesthetic evaluation.
