The Evaluation of a Wizard-Based Outpatient EMR in Oral and Maxilla Facial Surgery Department From the Aspects of Documentation Time and Record Quality — A Randomized, Cross-over Study

Abstract

Background: The electronic medical records(EMR) have been widely used in healthcare organizations all around the world, which is supposed having the potential to improve the efficiency in outpatient clinics. But the results about the function of EMR were controversial. We developed a Wizard-based outpatient EMR(WEMR) system dedicated to oral and maxillofacial surgery outpatient. Objective: To compare the efficiency of the Wizard-based outpatient EMR(WEMR) and the traditional keyboard character input outpatient EMR(TEMR), which was commonly used in oral and maxillofacial surgery outpatient. Methods: A well trained nurse, who was diagnosed with impacted lower third molar, acted as a standardized patient. 7 attending doctors and 21 interns were randomly allocated into two groups for EMR writing, one group writing medical records with TEMR, and the other with WEMR. And after 3 months of washout period, the writing tools were exchanged. A medical record scoring scale was produced for this standardized patient by three specialists. The documentary time and medical record quality scores of TEMR and WEMR were compared and analyzed. Results: The results showed that the documentary time decreased while the record quality score increased in WEMR group compared with TEMR group, and there were statistically difference between the two groups. At the same time, in the terms of record quality score comparison, the increase in interns group appeared to be greater than attending doctors group after using WEMR. Conclusions: The WEMR system can significantly reduce the documentary time and improve quality of medical records in outpatient of oral and maxillofacial surgery department. At the same time, the WEMR system can help the interns to master medical record writing skills.