To Analyze the Completeness of Electronic Medical Records (EMRs) during Tele-consultation for Making Diagnosis at Provider End: Emrs Completeness for Making Diagnosis at Provider End

Telemedicine is aimed to provide health care to rural populations, especially where there is a scarcity of resources. As telemedicine is unique among health care services, especially in developing countries, in lacking evidence of its effectiveness; the increasing demand advocates the clinical telemedicine to undertake more and better evaluations of its practicality, value, and affordability. To analyze the completeness and practicality of EMR Performa for making diagnosis at provider end during Tele-consultations, a study was conducted in PGIMER, a tertiary multispecialty referral institute that has been providing Tele-consultations to twenty partner sites in the Northern India. Service utilization data, patient demographics and diagnoses were collected for the period from July, 09 till December 09. The clinicians were requested to fill up a Pre-tested close ended Questionnaire after their Teleconsultation session was over. Out of 367 Tele-consultations received during study period, it was found that in 231 (62.9%) cases diagnosis could be made, while 136 (37.1%) cases remained un-diagnosed. On further analysis, it was found, that chief complaints were enumerated appropriately in 232 (63.2%) cases, History explained completely in 166 (45.2%) cases and Personal history in 194 (52.9%) cases. In 74 (20.1%) Tele-consultations, Vitals had been recorded, filled and General Physical Examinations done in 164 (44.5%) of cases. Investigations and diagnostic tests had been done in just 194 (52.9%) of cases. Pediatricians referred to this Telemedicine service (19.5% cases) more frequently than other specialties. Thus, stress need to focused on developing an appropriate and simple EMR Performa which may be filled easily and need modifications specialty wise, and, the referring physician need to be motivated to supply all the necessary clinical details to facilitate the Tele-consultant in making correct diagnosis.