Use of data from a hospital online medical records system by physicians during preanesthetic evaluation

Abstract

Objective. There is no data on the use of hospital-wide online edical record (OLMR) systems by anesthesiologists. We measured how often anesthesiologists accessed the OLMR database maintained by the hospital, how often data was copied from this database into the clinic's computer system, and how much data was copied.Methods. In a preanesthetic evaluation clinic that has a computerized evaluation system designed for physician-entered data, a graphical user-interface prototype link provided access to the hospital OLMR database for users and was studied over a 37-day period. The software allowed the user to search the OLMR system by patient name, retrieve a text listing of the patient's record, and then copy and paste desired information into the forms of the preanesthetic system. Using embedded routines, we recorded how many times physicians searched for and retrieved medical records from the hospital OLMR database, as well as how many times they copied data to the preoperative database. As a measure of howmuch data was copied, the number of characters was also recorded.Results. Of 1,080 patients evaluated in the clinic during the study period, electronic searches of the hospital OLMR database for 221 patients (20.5%) were noted. Of these searches, 208 (94.1%, or 19.3% of 1,080 patients) successfullyretrieved data from the patient's record. Data wascopied for 170 patients — 81.7% of the successful searches. Of 7,525,153 characters retrieved, 262,269 were copied — an average of 1,543 characters per instance of copying.Conclusion. We conclude that anesthesiologists, given even crude graphical access to a hospital OLMR database, will retrieve and copy data, potentially increasing the accuracy of the medical records and saving time.