Evaluation of the use of electronic medical record systems in Brazilian intensive care units

ABSTRACT Objective: To examine the prevalence of the use of electronic medical record systems in Brazilian intensive care units and the perceptions of intensive care physicians regarding the contribution of electronic medical record systems toward improving safety and quality in clinical practice. Methods: Using an online questionnaire, physicians working in Brazilian intensive care units answered questions about the use of electronic medical record systems in the hospitals in which they worked. They were asked about the types of electronic medical record systems used and their levels of satisfaction with these systems in terms of improving quality and safety. Results: Of the 4,772 invitations sent, 204 physicians responded to the questionnaire. Most used electronic medical record and prescription systems (92.6%), worked in private hospitals (43.1%), worked in general adult intensive care units (66.7%) and used Private System A (39.2%); most systems had been used for between 2 and 4 years (25.5%). Furthermore, the majority (84.6%) believed that the electronic system provided better quality than a paper system, and 76.7% believed that electronic systems provided greater safety than paper systems. Conclusion: Electronic medical record systems seem to be widely used by the Brazilian intensive care physicians who responded to the questionnaire and, according to the data, seem to provide greater quality and safety than do paper records.

摘要
目的：调查巴西重症监护病房（intensive care units）中电子病历系统（electronic medical record systems）的使用普及率，并调研重症监护医师对电子病历系统在临床实践中提升医疗安全与质量的贡献的认知。
方法：采用线上问卷的方式，向巴西重症监护病房的医师调研其所在医院的电子病历系统使用情况，询问其所使用的电子病历系统类型，以及对该系统在提升医疗质量与安全方面的满意程度。本次共发出4772份调研邀请，最终回收有效问卷204份。
结果：受访医师中，92.6%使用电子病历与处方系统，43.1%就职于私立医院，66.7%所在科室为成人普通重症监护病房，39.2%使用私有系统A（Private System A）；其中使用时长为2至4年的系统占比最高（25.5%）。此外，84.6%的受访者认为电子病历系统的记录质量优于纸质病历，76.7%的受访者认为电子系统相较纸质系统能提供更高的医疗安全保障。
结论：参与本次调研的巴西重症监护医师已广泛使用电子病历系统；且根据调研数据，电子病历系统相较纸质病历能够提供更优的医疗质量与安全保障。