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MDSs can improve the quality of service and provide important data to support cross-country planning and decision making in health care [ 15 , 48 , 49 ]. Minimum data sets often include two groups of demographic and clinical data [ 50 ]. Clinical data are used in diagnostic and treatment process and to help health care research, planning, and policy making [ 51 ].

Promoting information quality in EHR requires documenting necessary data about family and social history, medication usage, smoking and blood pressure, consultations, reasons of health care encounters, clinical findings and other information that facilitate clinical decision making and providing appropriate health care services [ 53 ]. There are a number of challenges for EHR implementation and a long way to its meaningful use in many countries [ 54 ]. The forecasting of a study showed given that there are no major policy changes, the maturity of EHR movement from a paper based environment to a fully electronic environment in the most US hospitals may take up to [ 55 ].

Managers and policy makers require an accurate assessment of the EHR implementation challenges in order to design an effective program for implementation of health information systems [ 54 ]. Collecting standard and required data from diverse health information systems can help to create more comprehensive health records such as population health record PopHR and community health record CHR. These records can provide a comprehensive vision of population health status and the factors that influence it by exchanging or receiving data from many national data sets and systems such as HISs and EHR.

Moreover they can be used by public health agencies in each country [ 56 , 57 ]. To our knowledge, this is the first study evaluating the inclusion of different demographic and clinical data elements in an EHR minimum dataset. This study sought the perspective of different groups of experts from different fields of health such as medicine, epidemiology, public health, health services management, health policy, medical informatics and health information management specialists as well as hospital directors, managers and IT and HIM administrators of educational hospitals in one of the top universities in Iran.

These participants are directly and indirectly engaged with patients and their information. This study had three limitations.

Electronic health records : a manual for developing countries

First, we did not seek the reasons for selecting every specific element by participants. Due to the long list of elements this could affect the participation and the response rate. Thus, recruiting more participants from other universities or employing other methods like Delphi technique or focus group discussion may yield more accurate results. However, this study evaluated the data elements of an electronic health record and proposed a refined version by adding complementary data elements.

Medical records manual a guide for developing countries

Using these results can help better implementation of EHR in Iran and improves information exchange from hospital information systems to EHR. Third, although developing the required minimum data sets is one of the main steps toward standardization of data exchange among health information systems, to achieve a high level of standardization other factors such as using common terminology, data structure, and data exchange protocols should also be addressed.

We suggest that future similar studies address these factors too. The results of this study showed that about one-third of the data communicated daily from hospital information systems to the electronic health records is unnecessary. Moreover, this study identified a number of necessary data elements that are not communicated to EHRs. The results of this study can help to enhance the accuracy and completeness of required data and to prevent data redundancy.

Health care authorities, policy makers, and administrators can utilize these results in order to enhance effectiveness of health services by providing relevant, complete and accurate information to providers at the point of care. The results of this study can be used by designers and developers of health information systems and EHR for developing new systems or upgrading current systems. This study presented a method to enhance the quality of clinical and administrative data collection and storage in universities and ministry of health databases.

The results of this study shed light on miscommunication of a number of clinical and administrative data elements to electronic health records. Based on these results, some necessary data elements are not recorded and communicated but some other unnecessary element are communicated. Lack of information such as clinical history and examination, reasons for the visits and family history can affect diagnostic process. Missing information related to operation, anesthesia, medications, allergies, specific conditions of patients and information about blood group and Rh compromises prevention and treatment processes of patients.

Since, one of the main purposes of EHR is providing access to health and treatment information of people, poor documentation of necessary information may adversely affect clinical decision-making, planning and policy-making in health care domain. This study was as a first step towards determining which data elements should be collected in Iranian national electronic health records by refining the current data sets. Collecting unnecessary data in an EHR leads to data redundancy, also, failure to send necessary data can reduce the quality of collected data.

The method employed in this study can be used by EHR developers and policy-makers to improve the quality of data collection and communication.

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The effect of an electronic health record system on nursing staff time in a nursing home: a longitudinal cohort study. Australas Med J. World H, Organization. Medical record manual a guide for developing countries. Secondary use of EHR: data quality issues and informatics opportunities. Summit on Translat Bioinforma. Standards for the content of the electronic health record.

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Int J Med Inform. Southern African Journal of Gerontology. Diversity in preoperative-assessment data collection, a literature review. Stud Health Technol Inform. Ahmadi M, Bashiri A. Hayrinen K, Saranto K. The core data elements of electronic health record in Finland. Pandza H. Minimal data sets for electronic medical Records in Hospital Settings. Acta Inform Med. Comput Inform Nurs. Nursing minimum data set in the multidisciplinary electronic health record. Developing a minimum data set for electronic nursing handover. J Clin Nurs.

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Patient Core data set. Comput Nurs. Basys CI, Credes I. Defning a minimum data set and related indicators for use with the system of health accounts in the European Union.


Luxembourg: IGSS. Iran's Ministry of Health. Accessed Nov Auber BA, Hamel G. Adoption of smart cards in the medical sector: the Canadian experience. Soc Sci Med. Kardas G, Tunali ET. Technical barriers such as a lack of a terminology standard for the EHR system was frequently found in studies of developed countries [ 33 ]. Electronic health data records were frequently incomplete due to different terminology standards. Based on the experience of EHR adoption in developed countries, the exchange of electronic health data plays an important role in EHR implementation [ 29 ].

Thus, the EHR system must be more universal, must apply a standardized terminology or protocol, must improve accuracy and must be applicable at each level of care. The review results have implications for regulators, healthcare organizations, and developers who are involved in the adoption of the EHR system to build a strategic plan for their organizations.

Regulators may also use the results as evidence to measure readiness before adopting a new EHR application and to develop the current EHR. In conclusion, readiness is important to enhance the possibility of the successful adoption of an EHR system in a healthcare facility. There are two enabling factors of readiness: individual readiness and organizational readiness.

Both are influenced by psychological and structural aspects.

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However, during the adoption process, there are several problems that may prevent the individual from fully accepting a new system and thus reduce organizational readiness, and such a situation may hinder EHR implementation in the primary care facilities of both developed and developing countries. Individual barriers such as unfamiliarity, organizational and financial barriers such as a lack of incentives, ethical-legal barriers such as a lack of policies, and technical barriers such as a lack of a terminology standard for EHR were common problems related to the implementation of an EHR system in developed countries.

For developing countries, the workload due to the complexity of the service, a lack of manpower, and poor teamwork were common problems which may cause the slow adoption of new health information technology such as EHR. This study has summarised the enabling factors and barriers with regard to EHR readiness in developed and developing countries.

Future research should build upon the results presented here and focus on the development of EHR implementation in primary health care. Conflict of Interest: No potential conflict of interest relevant to this article was reported. Healthc Inform Res. Published online Jul 31, Corresponding Author: Sandra Hakiem Afrizal.

Go to:. Objectives The aim of this study is to explore the enabling factors associated with readiness in Electronic Health Record EHR implementation and to identify the barriers related to readiness regarding the situation of primary health cares in developed and developing countries. Results Some barriers were found that may affect readiness, specifically individual barriers and organizational barriers. Conclusions This study summarized the enabling factors and barriers with regard to EHR readiness in developed and developing countries.

Selection Criteria The studies involved in this review met the following criteria. Based on previous studies, the enabling factors of readiness involved two major factors [ 21 , 22 ]: - Individual readiness: This factor is divided into individual psychological factors and individual structural factors. Empirical Phase From a total of 13 articles that were reviewed, it was found that 6 used quantitative studies Table 2. Enabling Factor of Readiness All of the enabling factors that influence readiness are discussed in the following articles Table 3. MeSH Terms. Developed Countries.

Developing Countries. Figures Show all Tables Show all KoreaMed Synapse. PubMed Central. Related citations. Download Citation. Go to: Abstract. Go to: I. Go to: II. Literature Review. Go to: III. Go to: IV. Table 2 Empirical phase of the review. Table 3 Enabling factors of readiness in the implementation of EHR.

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Table 4 Potential barriers in developed and developing countries. Go to: V. Go to: Notes. Go to: Acknowledgments. Go to: References. World Health Organization. Global strategy for health for all by the year Geneva, Switzerland: World Health Organization; Zayyad MA, Toycan M. Factors affecting sustainable adoption of e-health technology in developing countries: an exploratory survey of Nigerian hospitals from the perspective of healthcare professionals.

PeerJ ;6:e Evaluation of the quality of antenatal care using electronic health record information in family medicine clinics of Mexico City. BMC Pregnancy Childbirth ; Johnson RJ. A comprehensive review of an electronic health record system soon to assume market ascendancy: EPIC.

J Healthc Commun ;1 4 Electronic health records: manual for developing countries. Comparison of user groups' perspectives of barriers and facilitators to implementing electronic health records: a systematic review. BMC Med ; Health professionals' readiness to implement electronic medical record system at three hospitals in Ethiopia: a cross sectional study.


Readiness Assessment of Electronic Health Records Implementation

E-Health readiness framework from Electronic Health Records perspective. Int J Internet Enterp Manag ;6 4 In: Determining factors of organizational readiness for technology adoption in long-term care facilities.

Success criteria for electronic medical record implementations in low-resource settings: a systematic review. J Am Med Inform Assoc ;22 2 — United Nations. World economic situation and prospects Medical records manual: a guide for developing countries. Manila, Philippines: World Health Organization; Goldfarb NI.

Assessing quality of primary care through medical record review: lessons and opportunities. Health Policy Newsl ;13 2 In: E-Health systems: theory, advances and technical applications. Health Policy Technol ;6 1 — Primary health care: now more than ever. Enhanced teamwork communication model for electronic clinical pathways in healthcare. The semi-structured interviews are collected in South Africa, which is used as an example of a developing country.

South Africa; with one of the lowest ranked health services and also a resource restrained country; is a good example of a developing country.

Electronic Health Records: Usability and Unintended Safety Issues

The outcome of the research study is a comparative analysis of EMR systems in developed and developing countries including: implementation strategies; rate of adoption of EMR systems; challenges associated with the adoption of EMR systems and the benefits realised from the implementation of EMR systems. Size: 1. Format: PDF. Description: Conference paper. Login Register.