Call for Papers
Focus Theme: „Single Subject Research Design and Data Processing“
Deadline: Nov 1, 2016
Phone: +49 (0)711 - 2 29 87 88
Fax: +49 (0)711 - 2 29 87 65
send an Email
M. Dugas (1), S. Dugas-Breit (2)
(1) Institute of Medical Informatics, University of Muenster, Muenster, Germany; (2) Klinik und Poliklinik für Dermatologie und Allergologie, Ludwig-Maximilians-Universitaet, Munich, Germany
completeness, Medical documentation process, electronic dictation system, CRF, clinical trial documentation
Background: Physicians dedicate approximately a quarter of daily work to documentation. Completeness and speed of medical documentation processes are important parameters, because they can affect quality of healthcare.
Objectives: A generic method to monitor these quality parameters is proposed and its utility is demonstrated in two examples. Methods: Based on a generic event-driven process chain of a medical documentation process, completeness functions for created and finalized documents (available versus required documents by time) are defined. The 95%-quantile of process time is applied as performance indicator of documentation speed. A plotting function for these parameters is provided: completeness and speed of medical documentation (CSMD)-plot. Open source code and a sample data set are available in the Supplement.
Results: This methodology is applied to analyze the effect of an electronic dictation system on discharge letter documents. CSMD-plot detects significant differences regarding speed and completeness of the process before and after implementation of electronic dictation; in addition, it pinpoints differences regarding these quality parameters in documentation processes between different clinical departments. In a second example, CSMD-plot is used to analyze follow-up documentation of a clinical trial. Due to its generic design, CSMD-plots can be applied to other medical documentation processes such as order-entry processes.
Conclusions: Monitoring of completeness and speed of medical documentation is feasible and can provide quantitative information on these processes.
R. Sund 1, I. Nurmi-Lüthje 2, P. Lüthje 3, S. Tanninen 3, A. Narinen 2, I. Keskimäki1
Methods Inf Med 2007 46 5: 558-566
S. Herzberg (1, 2), F. Fritz (1), K. Rahbar (3, 4), L. Stegger (3), M. Schäfers (4), M. Dugas (1, 2)
Appl Clin Inform 2011 2 1: 1-17