title: Impact of immediate access to the electronic medical record on anatomic pathology performance.
abstract: OBJECTIVE
  To assess the overall impact of access to the electronic medical record (EMR) on anatomic pathology performance.
  
  
  METHODS
  We reviewed the results of all use of the EMR by 1 pathologist over an 18-month period.
  
  
  RESULTS
  Of the 10,107 cases (913 cytology and 9,194 surgical pathology) reviewed, the EMR (excluding anatomic pathology records) was accessed in 222 (2.2% of all cases, 6.5% of all cytology cases, and 1.8% of all surgical pathology cases). The EMR was used to evaluate a critical value in 20 (9.0%) cases and make a more specific diagnosis in 77 (34.7%) cases, a less specific diagnosis in 4 (1.8%) cases, and a systemic rather than localized diagnosis in 4 (1.8%) cases. The percentage of cases in which the physician was contacted decreased from 7.3% for the prior 18 months to 6.7%, but this change was not significant (P = .13). Twelve cases were subsequently sent for interinstitutional consultation, and no disagreements were identified.
  
  
  CONCLUSIONS
  The EMR was accessed in 2.2% of all surgical pathology and cytology cases and affected the diagnosis in 48% of these cases.
authors.affiliation: Dept of Pathology, Baptist Hospital of Miami, 8900 N Kendall Dr, Miami, FL 33176, USA.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Renshaw
authors.forename: Edwin W
authors.initials: EW
authors.lastname: Gould
mesh_terms: D000715:Anatomy / Q000592:standards; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D010336:Pathology / Q000592:standards*; D010340:Pathology, Surgical / Q000592:standards; D011785:Quality Assurance, Health Care / Q000706:statistics & numerical data*
keywords: Accuracy; Anatomic pathology; Consultation; Continuous quality improvement; Diagnosis; Electronic medical record; Quality assurance; Second opinion; Sensitivity; Surgical pathology