Electronic Medical Records and Mortality in Trauma Patients

• Published in: The Journal of trauma, injury, infection, and critical care Vol. 67; no. 3; pp. 634 - 636
• Main Authors: Deckelbaum, Dan L., Feinstein, Ara J., Schulman, Carl I., Augenstein, Jeffrey S., Murtha, Mary F., Livingstone, Alan S., McKenney, Mark G.
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins, Inc 01-09-2009; Lippincott Williams & Wilkins
• Subjects: Adolescent; Adult; Anesthesia; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Attitude of Health Personnel; Biological and medical sciences; Cohort Studies; Cost-Benefit Analysis; Diseases of the osteoarticular system; Female; General anesthesia. Technics. Complications. Neuromuscular blocking. Premedication. Surgical preparation. Sedation; Humans; Income; Injuries of the limb. Injuries of the spine; Male; Medical Records Systems, Computerized - economics; Medical Records Systems, Computerized - utilization; Medical sciences; Middle Aged; Outcome and Process Assessment (Health Care); Program Evaluation; Retrospective Studies; Trauma Centers; Traumas. Diseases due to physical agents; Wounds and Injuries - mortality; Wounds and Injuries - therapy; Young Adult; Human; Prognosis; Mortality; Documentation; Electronics; Physician; Anesthesia; Physician profiling; Medical record; Epidemiology; Trauma; Electronic medical record
• ISSN: 0022-5282; 1529-8809
• DOI: 10.1097/TA.0b013e3181a0fbce

BACKGROUND:The Electronic Medical Record (EMR) has been proposed as a way to reduce medical errors. It can also be used to document clinician involvement, which may affect outcomes. We sought to determine whether the EMR could be used to improve attending involvement in daily care, enhance surgical revenue, and lower mortality of patients with trauma.
METHODS:In 2004, the Trauma Division adopted a software program (CARE, Miami, FL) for creating an EMR and implemented a weekly report that was distributed to all members of the division and also to Departmental decision makers. Before initiation, explicit instructions were given to all surgeons that daily notes in the EMR were expected and would be followed by weekly reports. Before this, most notes were recorded in the paper chart and were difficult to track. Differences among proportions were determined with z test or χ, where appropriate with significance defined as p < 0.05.
RESULTS:With implementation of the EMR, daily and weekly reports were immediately available. Both attending surgeon documented notes and divisional annual revenue increased. A reduction in mortality was also observed.
CONCLUSION:The EMR can be used to change attending surgeon involvement in patient care and procedures. The increase in attending involvement was associated with an increase in revenue. Use of the EMR was associated with a significant reduction in hospital mortality.