Ohuabunwa Emmanuel C, Sun Jared, Jean Jubanyik Karen, Wallis Lee A
Yale School of Medicine, United States.
University of Cape Town, South Africa.
Afr J Emerg Med. 2016 Mar;6(1):38-43. doi: 10.1016/j.afjem.2015.06.003. Epub 2015 Jul 8.
Electronic Medical Records (EMRs) have shown benefit for clinical, organisational, and societal outcomes. In low-to-middle-income countries, the desire for EMRs will continue to rise as increasing trauma and infectious disease rates necessitate adequate record keeping for effective follow-up. 114 nations are currently working on national EMRs, with some using both a full EMR (Clinicom) and a paper-based system scanned to an online Enterprise Content Management (ECM) database.
The authors sought to evaluate the ability and completeness of the EMR at Khayelitsha Hospital (KH) to capture all Emergency Centre (EC) encounters classified as trauma. Based on the high trauma rates in the Khayelitsha area and equally high referral rates from KH to higher-level trauma centres, an assumption was made that its rates would mirror nationwide estimates of 40% of EC visits. Records from July 2012 to June 2013 were examined.
3488 patients visited the EC in the month of July 2012. 10% were noted as trauma on Clinicom and within their records were multiple sections with missing information. The remaining months of Aug 2012-June 2013 had an average trauma load of 8%. On further investigation, stacks of un-scanned patient folders were identified in the records department, contributing to the unavailability of records from January 2013 to the time of study (June 2013) on ECM.
The results highlight difficulties with implementing a dual record system, as neither the full EMR nor ECM was able to accurately capture the estimated trauma load. Hospitals looking to employ such a system should ensure that sufficient funds are in place for adequate support, from supervision and training of staff to investment in infrastructure for efficient transfer of information. In the long run, efforts should be made to convert to a complete EMR to avoid the many pitfalls associated with handling paper records.
电子病历（EMR）已显示出对临床、组织和社会成果有益。在中低收入国家，随着创伤和传染病发病率不断上升，对有效随访所需的充分记录保存的需求，对电子病历的需求将持续增长。目前有114个国家正在开展国家电子病历工作，其中一些国家同时使用完整的电子病历系统（Clinicom）和扫描到在线企业内容管理（ECM）数据库的纸质系统。
作者试图评估Khayelitsha医院（KH）的电子病历在记录所有分类为创伤的急诊中心（EC）就诊情况方面的能力和完整性。基于Khayelitsha地区较高的创伤率以及KH向更高水平创伤中心的同样高的转诊率，假设其比率将反映全国估计的40%的急诊就诊率。对2012年7月至2013年6月的记录进行了检查。
2012年7月有3488名患者前往急诊中心就诊。在Clinicom上记录为创伤的患者占10%，其记录中有多个部分信息缺失。2012年8月至2013年6月的其余月份创伤患者平均占8%。进一步调查发现，记录部门有大量未扫描的患者文件夹，这导致2013年1月至研究时（2013年6月）的记录无法在ECM上获取。
结果凸显了实施双重记录系统的困难，因为完整的电子病历系统和ECM都无法准确记录估计的创伤患者数量。希望采用这种系统的医院应确保有足够资金提供充分支持，从员工的监督和培训到高效信息传输基础设施的投资。从长远来看，应努力转换为完整的电子病历系统，以避免处理纸质记录带来的诸多问题。
