Electronic health records and online medical records: an asset or a liability under current conditions?Judith Allen-Graham A B G , Lauren Mitchell B , Natalie Heriot A , Roksana Armani A , David Langton A C , Michele Levinson A D , Alan Young A E , Julian A. Smith A F , Tom Kotsimbos A B and John W. Wilson A B
A Monash University, Wellington Road and Blackburn Road, Clayton, Vic. 3800, Australia. Email: email@example.com; firstname.lastname@example.org; email@example.com; firstname.lastname@example.org
C Peninsula Health, 2 Hastings Road, Frankston, Vic. 3199, Australia.
D Cabrini Private Hospital, 181–183 Wattletree Road, Malvern, Vic. 3144, Australia. Email: email@example.com
E Eastern Health, Level 2, 5 Arnold Street, Box Hill, Vic. 3128, Australia. Email: firstname.lastname@example.org
F Monash Medical Centre, 246 Clayton Road, Clayton, Vic. 3168, Australia. Email: email@example.com
G Corresponding author. Email: firstname.lastname@example.org
Australian Health Review - https://doi.org/10.1071/AH16095
Submitted: 28 April 2016 Accepted: 13 November 2016 Published online: 20 January 2017
Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information.
Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n = 200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital’s current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary.
Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution.
Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services.
What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This causes inefficiencies in the recall of patient information and can potentially lead to incidences of adverse drug events.
What does this paper add? This paper supports the concept of a shared medical record system using 200 audited patient records across five Victorian metropolitan hospitals, comparing the current information systems in place for healthcare practitioners to retrieve data. This research identifies the degree of concordance between these sources of information and in doing so, areas for improvement.
What are the implications for practitioners? Implications of this research are the improvements in the quality, storage and accessibility of medical data in Australian healthcare systems. This is a relevant issue in the current Australian environment where no guidelines exist across the board in medical history documentation or in the distribution of discharge summaries to other healthcare providers (general practitioners, etc).
Additional keywords: adverse drug event (ADE), eHealth, electronic medical record (EMR), medical history.
References Australian Institute of Health and Welfare (AIHW). Australia’s health 2012. Canberra: AIHW; 2012.
 Bishop TF, Press MJ, Mendelsohn JL, Casalino LP. Electronic communication improves access, but barriers to its widespread adoption remain. Health Aff 2013; 32 1361–7.
| Electronic communication improves access, but barriers to its widespread adoption remain.CrossRef |
 Australian Digital Health Agency (formerly National E-Health Transition Authority). Sydney: Australian Government; 2014. Available at: http://www.digitalhealth.gov.au/about-the-agency [verified 24 April 2016].
 Murphy J, Ley S. Patients to get new myHealth Record: $485m ‘rescue’ package to reboot Labor’s e-health failures. 2015. Available at: https://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015-ley050.htm [verified 24 April 2016].
 Deloitte. Expected benefits of the national PCEHR system. Based on economic modelling work undertaken in 2010–2011. 2012. Available at: http://www.aph.gov.au/~/media/Estimates/Live/clac_ctte/estimates/bud_1213/DoHA/tabled_docs/DeloitteExpectedBenefitsPCEHR.ashx [verifed 19 April 2016].
 Armani R, Mitchell LE, Allen-Graham J, Heriot NR, Kotsimbos T, Wilson JW. Current patient and healthcare worker attitudes to eHealth and the personally controlled electronic health record in major hospitals. Internal Med J 2016; 46 717–22.
| Current patient and healthcare worker attitudes to eHealth and the personally controlled electronic health record in major hospitals.CrossRef | 1:STN:280:DC%2BC28fmt1ensw%3D%3D&md5=e139628e77aac095691ad787f80596faCAS |
 Health Information Management of Australia (HIMAA). General clinical information and documentation requirements. 2006. Available at: http://www.himaa.org.au/Pubs/HIMAA_Practice_Brief_2006.pdf [verified 24 April 2016].
 Australian Commission on Safety and Quality in HealthCare (ACSQHC). Electronic discharge summary systems literature scan. 2010. Available at: http://www.safetyandquality.gov.au/wp-content/uploads/2012/02/e-DischargeLiteratureScan.pdf [verified 20 April 2016].
 NSW Health. Health care records – documentation and management. 2012. Available at: http://www0.health.nsw.gov.au/policies/pd/2012/pdf/PD2012_069.pdf [verified 24 April 2016].
 Riskman Industry experts. 2014. Available at: http://www.riskman.net.au/Methodology/Industry-Experts [verified 16 April 2016].
 Belleli E, Naccarella L, Pirotta M. Communication at the interface between hospitals and primary care. A general practice audit of hospital discharge summaries. Aust Fam Physician 2013; 42 886–90.
 van Walraven CSR, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med 2002; 17 186–92.
| Effect of discharge summary availability during post-discharge visits on hospital readmission.CrossRef |
 Australian Government. Australia to 2050: future challenges. Australia to 2050: Future challenges. The 2010 intergenerational report. Overview. 2010. Available at: https://archive.treasury.gov.au/igr/igr2010/Overview/pdf/IGR_2010_Overview.pdf [verified 23 November 2016].
 Blumenthal D, Tavenner M. The ‘meaningful use’ regulation for electronic health records. N Engl J Med 2010; 363 501–4.
| The ‘meaningful use’ regulation for electronic health records.CrossRef | 1:CAS:528:DC%2BC3cXpsl2lsL4%3D&md5=ea2596e0c1feaf4ae1e51d9555303677CAS |