Thực trạng dạy học lâm sàng môn truyền nhiễm và hiệu quả can thiệp bằng sử dụng bệnh án điện tử tại đại học y khoa vinh tt tiếng anh

MINISTRY OF EDUCATION
MINISTRY OF HEALTH
AND TRAINING
HANOI MEDICAL UNIVERSITY

NGO TRI HIEP

THE CURRENT SITUATION OF CLINICAL TEACHING
OF INFECTIOUS SUBJECT AND INTERVENTION
EFFECTIVENESS BY USING ELECTRONIC MEDICAL
RECORD AT VINH MEDICAL UNIVERSITY

Specialization: Social Hygiene and Health Organization
Code: 62720164

SUMMARY OF DORTORAL THESIS

HA NOI – 2020


This thesis was completed at:
HANOI MEDICAL UNIVERSITY

Supervisors:
1. Assoc. Prof. Trinh Hoang Ha
2. Assoc. Prof. Nguyen Van Huy

Reviewer 1:

Reviewer 2:

Reviewer 3:

The thesis will be defended in front of the PhD Thesis Assesement
Panel, Hanoi Medical University
At …… on 2020

The thesis could be found at:
- Vietnam National Library
- Library of Hanoi Medical University.


INTRODUCTION
Clinical teaching (CT) is a special part of medical education in general
and teaching of general medical students, in particular. CT occupies a large
part in training programs of medical universities in the world as well as in
Vietnam. Throughout clinical practice (CP) process, students are able to
apply theoretical knowledge learned to make decisive diagnosis, offer
treatment, address situations, monitor and prognose patients.
There are many CT methods applied in training for students at the
hospital. CT by medical record commentary (MRC) and case discussion
becomes indispensable methods in medical universities. Practicing of the
medical record-making skills (MRMS) is one of the solutions to improve the
effectiveness and quality of CT.
At present, there is a fact that many medical universities still lack a team
of highly qualified lecturers. Lecturers also participate in many tasks. Besides,
a part of students is still passive, lack of motivation, lack of knowledge, skills,
and creativity affect learning efficiency. In addition, the change in population
structure, disease patterns, hospital regulations, people's intellectual life, the
explosion of information tecnology (IT) also directly affects the CT process.

Researches on CT have been conducted in some universities.
Researches focus on CT characteristics and improve the effectiveness of CT
through applicating of active teaching methods. The feasibility of the
interventions also depended on the factors and conditions of each university.
The application of IT in CT has not been fully mentioned and studied.
Vinh Medical University (VMU) was established in 2010. Since 2011,
the University started training medical students. In the condition of
increasing infectious diseases, training of general practitioners with
adequate knowledge and skills on infectious diseases is a requirement for
the people's health care. From that fact, the question is given that how is the
current stuation of infectious CT in the VMU and if can apply IT to create
the electronic medical record (EMR) to support medical students in making
the medical record (MR) better from which to improve the efficiency and
quality of CP process? To find the answers to the above questions, we
implemented the application of E-learning technology using Moodle software
to design the EMR for supporting medical students in clinical practice of
infectious subject. The thesis was implemented for the following objectives:
1. Describe the current situation of clinical teaching of infectious
subject for medical students at Vinh Medical University.


2. Evaluate the intervention effectiveness by using the electronic medical
record in infectious clinical teaching for medical students at Vinh Medical
University.

NEW CONTRIBUTIONS OF THE THESIS
The thesis results provided evidences on the current situation of
infectious CT, showed some limitations which affecting the effectiveness of
CT. Intervention by using the EMR to help students make infectious
medical record (IMR) through E-learning course has achieved certain

effectiveness. High intervention effectiveness (IE) was recorded in the
contents of the MR; the positive evaluation of students on the course, selfevaluation of MRMS have improved better. The project is practical, feasible
to overcomes a number of limitations in CT, is suitable with the trend of IT
application and meets the needs of the university, lecturers and students. The
thesis also opens up a new direction in CT that is the application of IT not
only for MRMS but also for other areas.
ARRANGEMENT OF THESIS
The thesis consists of 130 pages, excluding appendices, in which:
Introduction of 2 pages, an overview of 35 pages of documents, the research
methodology of 18 pages, the research results of 36 pages, the discussion of
35 pages, conclusion of 2 pages, recommendations 2 pages. The references
were written standardly, there were 112 references, including 38 documents
updated within 5 years, accounting for 33.9%.
CHAPTER 1. OVERVIEW
1.1. Some basic concepts
1.1.1. Medical student
General medical students are students who study to become a general
practitioner who treats acute and chronic diseases, proposes preventive
measures, rehabilitates health and prescribes medicine for patients.
1.1.2. Infectious Diseases
Infectious diseases are diseases that can spread directly or indirectly to
surrounding individuals and tend to cause epidemics in population
communities.
1.1.3. Medical Record
The Medical Record (MR) is a document that records everything
necessary for understanding the situation of the patients’diseases from the
time of admitting to the time of discharge. The MR is done by the physician as
soon as possible when the patient enters the hospital and records all the
information related to the patient including name, age, address, occupation,
arising status, and disease progression.

1.1.4. Infectious Medical Record


The IMR is a MR sample that is formulated when a patient is admitted
to the department of infectious disease. The IMR presents the personal
patient's information, the patient's condition upon admission, the diagnosis
of the physician, and the patient's examination results.
1.1.5. Electronics Medical Record
The EMR is a digital version of a MR, recorded, displayed and stored
by electronic means, with the legal basis and the equivalent function to the
paper MR, specified in the Law on Examination and Treatment.
1.1.6. Information Technology
IT is an engineering branch that uses computers and computer software
to convert, collect, store, protect, process and transmit information.
1.1.7. Terminology concept of E-Learning
E-learning is the process of learning through electronic means, the
Internet, and Web technologies. The content is distributed to the classrooms
via the Internet, Extranet, audiotapes, videos, broadcast satellites, television,
CD - ROM and other electronic media.
1.1.8. Moodle concept
Moodle is an open-source online learning management system, also
known as Course Management System or Virtual Learning Environment,
which allows creating courses on the Internet or online Web pages.
1.2. Overview of clinical teaching
1.2.1. The role and goals of clinical teaching
CT often makes up a large proportion of medical staff training programs in
medical universities. Through CT, students will achieve 3 common goals: 1)
Learning attitudes, behaviors, and behaviors. 2) Learning knowledge and career
skills. 3) Training the clinical thinking style, working style of health staff;
learning methodology; forming self-study, self-researching, and building the

working capacity.
1.2.2. The features of clinical teaching
CT takes place in hospitals, clinics, and is closely related to the task of
healthcare for patients. The relationship between teachers and students will
motivate students to behave more flexibly to facilitate learning with good
results. CT is flexible in many places, many forms with different content and
forms of learning. The CT process requires teachers, students to be proactive,
organized and methodical to achieve the best results.
1.2.3. The current situation of clinical teaching
CT plays an important role in medical training. The method of
education requires promoting students' activeness, self-awareness, initiative,
and creativity. Since the 1980s, innovations in teaching methods at medical
universities have begun to be paid attention but moving slowly.
In fact, the CT skills and practices is gradually being forgotten and


overlooked at some medical universities in the world. CT methods also tend
to confuse CP teaching with theoretical teaching. Students do not know the
CP skills. Active teaching methods have not been widely disseminated. The
organization and support of lecturers to make the CP process become more
proactive and effective has not been paid enough attention. The trend of
floating CT, wasting training time are very common and serious in many
universities. Many important goals are neglected. There is an imbalance
between theory and practice; less teaching organization, management,
statutes, rules, working style; a little combination of teaching community
medicine skills, communication skills, counseling, health education, how to
solve community-related health problems. The university-hospital
combination is not adequate which effects the hospital’s benefits as well as
the student's academic results. Defects in CT not only occur in a few
universities but also can be seen in most medical universities.

1.2.4. Several active clinical teaching methods
Some active teaching methods are used in the world and in Vietnam.
Including 1) Small group teaching; 2) Problem Based Learning; 3) Teaching
by case studies; 4) Teaching by roleplay; 5) Teaching by the bedside; 6)
Teaching with progression diagram or flowchart; 8) Teaching by checklist.
1.2.5. Some solutions to improve the effectiveness of clinical teaching
There are many solutions to improve the efficiency of CT. Depending
on the universities, the time to apply. Some solutions are: 1) Giving students
early access to CT environment; 2) Improving the quality of clinical
lecturers; 3) Improving the quality of CT methods with patients; 4)
Innovating clinical evaluation methods; 5) Enhancing the application of IT
in CT, and 6) Organizing students to self-study clinically.
1.2.6. Some domestic and foreign studies on clinical teaching
Le Van Cuong's study in 2008 applied active clinical learning methods
on 145 medical students, of which 78 students in the 3rd-year and 67
students in the 6th year were divided into 15 groups.
Research by Tran Thi Thanh Huong, Le Thu Hoa et al in 2002 on 143
teachers and 1360 students of Hanoi Medical University on CT methods.
Research of Vu Dinh Chinh, Tran Thi Minh Tam, Nguyen Thi Lien et
al in 2006 on CT method.
Research by Truong Viet Truong, Nguyen Thi Quynh Hoa et al in
2015 on regular students of Thai Nguyen University of Medicine and
Pharmacy.
Pham Thi Hanh's study in 2018 on medical students from Hai Phong
University of Medicine and Pharmacy on the status of CT and intervention
through positive teaching methods.
Research of Nguyen Thi Quynh Nga in 2017 at VMU on CT method.
The study of Mc Manus I. C, Richards P, Winder B.C in 1998 on 4,000

students at Marry Medical University in London on study habits affects the
amount of clinical knowledge.
Research of Ghasemzadeh I et al in 2015 on students of Hormozgan
University of Medical Sciences, Iran on the medical teaching method.
Research of Seki Masayasu et al in 2016 on the clinical learning model of
students.
Research of Guishu Zhong and Xia Xiong in 2010 on students of
Lusho Medical University on some factors related to clinical learning.
Josephine L. Dorsch et al in 2004 studed on 3rd-year medical students
on evidence-based CT.
Research of Sarah Parrott, Llison Dobbie, Heidi Chumley in 2006 and
Research of Wolpaw Terry in 2012 on positive teaching methods.
1.3. Overview of the medical record and electronic medical record
1.3.1. The role of medical record
MR is medical and legal documents. Each patient has only one MR per
medical examination, and treatment at a health facility. Internship students,
researchers, practitioners in medical examination and treatment facilities
may borrow on-site MR to read or copy in service of research or
professional and technical work. The role of MR: 1) Helping properly
diagnose and treatment, disease monitoring, professional improvement; 2)
Serving scientific research work; 3) Administrative and legal documents
base.
1.3.2. Basic functions of medical record
The MR has the following functions: 1) Helping to identify and store
patient records; 2) Managing the patient's anthropometric data; 3) Managing
patient-specific issues; 4) Managing the list of medicines for patients; 5)
Managing patient's medical history 6) Managing notes and documents: creating,
supplementing, editing, and verifying information; 7) Creating the patient
clinical documents from external sources; 8) Providing appropriate patient care
planning, guidance, and implementation; 9) Summarizing and recording specific

patient instructions.
1.3.3. The structure and content of infectious medical record
The IMR has a basic structure of internal MR including 11 contents: 1)
Administration; 2) Reasons for hospitalization; 3) History; 4) Pre-history; 5)
Physical examination; 6) Summary of MR and preliminary diagnosis; 7)
Subclinical testing; 8) Diagnosis; 9) Treatment; 10) Prognosis; 11) Prevention,
health education.
1.3.4. The electronic medical record
The EMR is a digital version of the MR, which is recorded, displayed, and
stored by electronic means, has the same legal basis, and functions as the paper
MR prescribed in Article 59 of the Law on Medical Examination and
Treatment. The content of the EMR shall include all information fields in the
form of MR used in medical examination and treatment facilities. The use of the


EMR is a new step in medicine leading to changes in healthcare and medical
research.
In this project, the EMR is a MR sample designed on the basis of the
contents of an IMR based on the application of Moodle software and Elearning technology. When using the EMR, medical students are assisted in
MRMS to improve the effectiveness of internships, suitable in the era of IT,
and the lack of lecturers.
1.3.5. Some research works on the medical record–making skills and the
electronic medical record
Specialized case studies of medical students are often limited and
integrated with other clinical skills. Assessments of clinical skills are
expressed in evaluating communication skills, examination skills, reasoning
skills in making clinical diagnosis decisions, and health education
counseling skills.
Pham Thi Hanh's study in 2018 at Hai Phong University of Medicine
and Pharmacy through intervention with positive CT methods.

Research by Nguyen Duc Linh, Nguyen Thi Thanh Quyen, Ho Thi Le
et al 2011 in Tay Nguyen University on CP skills.
Nguyen The Hien’s study in 2016 at medical universities on the quality
assurance status of general practitioner education.
Research by Ivan Solarte, Karen D. Könings in 2017 at San Ignacio
Universitario Hospital - Colombia, EMR programs and policies for students.
Research by R. Jacobs, M. Kane in 2019 on medical students in the
United States on the use of the EMR for students.
Research by White, Jordan et al in 2017 on the method of using the
EMR with medical students.


1.4. Application of information technology (IT) in medical training
1.4.1. Current situation of information technology application in medical
teaching
IT plays a role in the advancement of medicine today and motivates
medical students to study, solve problems, and many other benefits. In the
clinical environment, the traditional method of disclosing inadequacies is not
having enough time for clinical lecturers to interact with students. An increase in
the number of students learning leads to the lack of clinical lecturers, limiting
the self-study spirit, limiting the skill level of students. An opportunity set for
medical education is to apply IT to achieve its goals in teaching and learning. In
2017, the Prime Minister issued Decision 117/QD-TTg approving the Project
"Strengthening the application of IT in management and supporting teachinglearning and scientific research activities, contributing to improving the quality
of education and training in the 2016-2020 period, with orientations toward
2025”. However, medical universities in Vietnam have not yet effectively
applied IT to education, especially in CT.
1.4.2. E-learning teaching method
E-learning is a term used to describe learning and training based on
information and communication technology, especially IT. From a modern

perspective, E-learning is the distribution of learning content, using modern
electronic tools such as computers, satellite networks, Internet, Intranet.
Through a computer or television, teachers and learners can communicate
with each other via the Internet in forms such as email, online
discussion,forum, seminars, videos. From 2000 to the present, E-learning has
created a revolution in education and training. E-learning has advantages: not
limited by space and time; increased attractiveness; flexibility; updating; there
are cooperation and coordination in learning; create pleasant psychology for
teachers and learners. E-learning has disadvantages that are: high technical
cost; limited social communication skills; restricting experimental practices
and requiring high personal awareness.
The functional model of an E-learning system consists of 2 parts:
Learning Content Management System and Learning Management System.
The system model consists of 3 main parts: 1) Communication infrastructure
and network. 2) Software infrastructure. 3) Content of training.
1.4.3. Moodle course management system
Moodle is an open-source online learning management system that
allows creating courses on the Internet or online learning websites. The
characteristics of Moodle are: 1) Free and open source; 2) Educational
philosophy; 3) Community. Moodle has outstanding features compared to
other CMS systems such as Blackboard, WebCT that help educators
organize courses, effectively distribute learning materials, and introduce


innovative teaching methods.
1.5. Clinical training program of infectious subject
The program and contents of infectious CP are conducted in the
mornings for 4 weeks. The learning contents include briefings; MRC;
examination, diagnosis of diseases; treatment of diseases; lecturing, and
studying in the patient chamber; join directly on schedule. At the end of the

CP, the assessment was organized through grading the MR.
Stage 1: Studying the current stuation of infectious CT
Stage 2: Developing an E-Learning course to guide the infectious MRmaking and designing of the EMR sample
To assess the
MRMS of the group
without using EMR
for the first time at
the end of week 1

Stage 3:
Evaluating the
effectiveness of the
EMR on subjects

To assess the MRMS of the group
without using EMR for the second
time at the end of week 4

To assess the
MRMS of the
group using EMR
for the first time at
the end of week 1

To assess the MRMS of the
group using EMR for the second
time at the end of week 4

To assess the effectiveness of the EMR through
comparing 2 groups after intervention

Figure 1.1: Diagram research
CHAPTER 2. SUBJECTS AND METHODOLOGY
2.1. Research setting and research subjects
2.1.1. Research setting
At VMU and CP facilities for infectious subjects, including Faculty of
Tropical Diseases - Nghe An General Friendship Hospital; Faculty of
Tropical Diseases - Vinh City General Hospital; Faculty A4-Military
Medical Hospital 4.
2.1.2. Research subject
- Medical Student (5th year);
- Organic and visiting clinical lecturers;
- Leaders, managers, lecturers' representatives.
2.2. Duration of Research
- From October 2017 to March 2018: Researching the current stituation
of infectious CT for medical students of VMU.


- From April 2018 to October 2018: Designing and completing the
EMR on Moodle software, building an E-learning course.
- From November 2018 to April 2019: Interventions on medical
students using the EMR through the E-Learning course on guidelines for
making the IMR.
2.3. Research methodology and contents
2.3.1. Research design
2.3.1.1. Research design for Objective 1
Cross-sectional descriptive research design, quantitative research.
2.3.1.2. Research design for Objective 2
The controlled intervention research design was used, combining
quantitative research with qualitative research.
- Quantitative research: comparing the results of the intervention group

before and after with the control group to evaluate the effectiveness of the EMR
intervention.
- Qualitative research: focus group discussions and acceptance of the
EMR from university leaders, managers, and lecturers.
2.3.2. Sample size and sample selection
2.3.2.1. Sample size and sample selection for objective 1
- Calculating sample size:
+ Sample size of student group: All medical students of 2013 – 2019
course: a total of 367 students.
+ Sample size of lecturer group: All clinical lecturers of the Department
of Infectious Medicine (including visiting lecturers): a total of 27 lecturers.
- Method of sampling: All research subjects, including lecturers and
students, were sampled to ensure the selection criteria: healthy and not
disciplined; have good research cooperation attitude; voluntary
participation.
2.3.2.2. Sample size and sample selection for objective 2
- Calculating sample size:
+ Sample size for intervention research: the research subjects are general
medical students in the 2014-2020 course. Using the formula for calculating the
sample size of the controlled trial, comparing the 2 rates of the IMR in the
qualified level of 2 groups after being intervened with the EMR:

z
n=

1− / 2

2 P (1 − P ) + z1− 

P1 (1 − P1 ) + P2 (1 − P2 )



2

( P1 − P2 ) 2

In which:
- n: the minimum sample size for intervention.
- P1: expected rate of the intervention group to make a qualified IMR,
taking p2 = 85%.
- P2: expected rate of the intervention group to make a qualified IMR
after intervention by the EMR, taking p2 = 85%.
- P average = (p1 + p2) / 2. The average P was 77.5%.


- Z (1-α / 2) = 1.96 (corresponding to the desired significance level, α =
0.05).
- Z (1-β) = 0.842 (corresponding to the strength β = 85%).
Thus, it was calculated by 138. Preventing the research subjects not
participating, we provided an additional 10% and the sample size was 152 students
for each group.
+ Sample size for group discussions: Including university leaders,
managers, lecturers: about 10 people.
- Selection of the research sample:
+ There were 308 medical students in the 2014-2020 course selected
for research. All students have the same characteristics, evenly distributed in
4 classes: Y14A, Y14B, Y14C, Y14D. Based on the schedule of infectious
CP provided by the Training Department and to ensure the objectivity in
evaluating the IE of EMR, we divided into 2 groups (the intervention and

the control) based on the time of CP at the facility. The CP schedule of the
classes was completely random provided by the Training Department from
the beginning (August 2018). The list of students in the class was arranged
according to the regulations upon admission (2014). With this division, the
control group would be contactless and known the EMR. The intervention
group would be followed by the EMR. Students were assured of the
following standards: 1) Healthy, not disciplined; 2) Having good research
cooperation attitude; 3) Voluntary participation. Specifically:
* Control group: Y14A and Y14D with a total of 156 students during the
CP period from November 19, 2018, to January 14, 2019.
* Intervention group: Y14B, Y14C with a total of 152 students during CP
period from January 15, 2019, to March 31, 2019.
The CP group used the
EMR throughout the
course
Intervention group

Students
started the
infectious
CP at the
facilities

The CP group not
used the EMR
throughout the course

Control group

Figure 2.1: Diagram of CP process of two research groups

+ Intentional sampling for group discussion: university leaders (2
people), managers of the training department (3 people), clinical lecturers (5
people - 2 faculty members, and 3 visiting lecturers). A total of 10 people.
2.3.3. Research contents
2.3.3.1. Research contents for objective 1
- The actual situation and opinions of CT staff:
+ The actual situation of CT lecturer staff (quantity, age, professional
level, educational level, working seniority, seniority in CT, training in
medicine pedagogy, and CT confidence);
+ Lecturer's opinion about contents of CT plans; CT methods; Contents


of the CT organization; Contents of CP assessment and student MR-making;
Forms of evaluating CP results; Lecturers' needs for some topics related to
CT; Needs to apply IT and the EMR in CT.
- The current situation of CP and students' opinions on CT:
+ General information about students (gender, religion, ethnicity, CP
facility);
+ Students' opinions on CT: Satisfaction level of students on
conditions of CP facilities; contents of the training program; CT forms of
lecturers; advantages and difficulties when CP; some contents in
management, CT skills, organization, evaluation of CP results; the situation
of learning via MRs; students' needs for some topics related to CT; IT
application needs in CP; knowledge of The EMR and needs of use and
testing of The EMR.
- Collecting available data: human resources, types of equipment of CP
facilities, and the content of training programs for CT.
2.3.3.2. Research contents for objective 2
- Comparing the average score of MRMS before and after the
intervention and compared with the control group; calculating the

effectiveness index, IE; the relevance of CP results with the 11 contents of
the MR results.
- Students self-assess about the adequate level of MRMS after
intervention.
- Students' feedback on about the E-learning course includes the
objectives and content; the organization and management; the training
method; the assessment methods; the facilities; the effectiveness; the most
satisfying thing; the least satisfying thing; the advantages of applying IT in
CT; replicating the course model.
- Opinions and acceptance of university leaders, managers, and
lecturers on the EMR include the urgency, significance; form; structure;
accuracy, science, standard of medical terminology, and updating of the
EMR; suitability with medical students; conditions for application the EMR.
2.4. Steps to conduct research
2.4.1. Stage 1: Researching the current stuation of infectious clinical
teaching for medical students
The study focused on describing the reality of the CT of infectious
subjects. This phase carried out 3 contents: 1) Assess the current situation of
CT activities of the staff; 2) Assess the status of students' CP; 3) Collecting
available data on the clinical training program of infectious subjects and
human resources, equiments of CP facilities.
2.4.2. Stage 2: Developing an E-learning course to guide medical recordmaking and designing of the electronic medical record
- Develop the content for the E-Learning course to guide MR-making.
The course was based on the website "Online training system" under
the project "Human resource development program" of the Ministry of
Health. The system is operated by Hanoi Medical University. Fellows create


courses that include: 1) Developing an "E-learning course to guide making
the IMR"; 2) Request a domain name and create a specific address online; 3)

Create a homepage and content for the course.
- Designing the EMR.
+ Building content structure of the EMR: Based on the structure of
IMR, graduate students design the content structure of The EMR to every
detail in the sections and information related to the Clinical situations and
suggestions for solutions. Each situation would help students not to forget
the information of patients, choose the appropriate solution.
+ Designing the EMR on the E-learning course: The whole content of
the EMR structure was designed and integrated into the lecture in the form
of activity. Using the module "Questionaire" to design the EMR according
to 11 contents: 1) Administrative information; 2) Reasons for
hospitalization; 3) History; 4) Pre-history; 5) Physical examination; 6)
Summary of MR and preliminary diagnosis; 7) Proposal for subclinical
testing; 8) Summary of MR and definite diagnosis; 9) Treatment; 10)
Prognosis of disease; 11) Prevention, health education. Each content has
detailed questions that prompt students to explore and there are situations
for students to choose. The suggested situations can be in the following
forms: fill in the text in the answer box (Assay Box), check multiple options
(Checkboxes), enter the answer in text form (Text Box); Yes/No option
(Yes/No); fill in the numerical form (Numeric); fill out the date (Date);
choose a situation in many situations (Radio Buttons), choose by the rate
(Rate - Scale 1 ... 5) or select a case of a box type (Dropdown Box). After
completing all contents of the EMR, the software would saved the student's
selections. Students would have a full copy of the patient information that
could be printed on paper or stored in the device and proceeded to write a
complete MR.
- Apply testing to learn about content technical issues.
- Correction of technical and content errors, aesthetic.
2.4.3. Stage 3: Evaluating the efficiency of the electronic medical record
on research subjects through E-learning course using Moodle software

2.4.3.1. Dividing the intervention group and the control group
The research subjects were divided into 2 groups. The CP activities of
the two groups was conducted the following process:
- The control group was instructed to make the IMR in the usual way
in the first week of CP. At the end of the first week, students had to make
and submit the IMR according to the unified form (pre-intervention). From
the second week, they continued the scheduled of CP (not using the EMR).
Students had to make the IMR the second time according to the unified form
at the end of the 4th week (Post-intervention). Lecturers would assess both
of times of the MRMS and the results of the CP process would be graded for
the second time.
- The intervention group also was instructed to make the IMR in the
usual way in the first week of CP. At the end of the first week, students had


to make and submit the IMR according to the unified form (preintervention). From the second week, students were given the account and
the instructions on how to access the course to continue the application of
the EMR in CP. Students made the IMR according to the unified form at the
end of the 4th week (Post-intervention). Lecturers would assess MRMS and
the results of the CP process would be graded for the second time.
2.4.3.2. Intervening by using the EMR
The intervention group was provided with an account, password to
access the course. They exploited the course content and used the EMR
during CP process. There were 6 activities that students had to participate in:
forums, online discussions (chats), using the EMR, completing selfassessment form, filling in the form of course feedback, and summiting the
IMR.
2.4.3.3. Evaluating IE by using the EMR through the E-learning course
- Developing a "The sheet of evaluating MRMS" with scoring for
the criteria uniformly.
- Evaluating the EI of EMR based on 4 contents.

2.5. The standard of evaluation
The evaluation of MRMS followed the unified form below.
Table 2.1: The evaluation score for medical record-making skills
Contents
Maximum Fairly good
No
of evaluation
Score
Score
1
Exploiting the administration
5 scores
≥ 3.5 scores
information
2
Exploiting the reasons for
5 scores
≥ 3.5 scores
hospitalization
3
Historic exploitation
15 scores
≥ 10.5 scores
4
Pe-historic exploitation
10 scores
≥ 7 scores
5
Physical examination
15 scores

≥ 10.5 scores
6
Summary of MR and preliminary
10 scores
≥ 7 scores
diagnosis
7
Proposal for subclinical testing
10 scores
≥ 7 scores
8
Reasoning, definite diagnosis
10 scores
≥ 7 scores
9
Treatment of disease
10 scores
≥ 7 scores
10 Prognosis of disease
5 scores
≥ 3.5 scores
11 Prevention, health education
5 scores
≥ 3.5 scores
Total = 100 scores ≥ 70 scores
Each content had many criteria. Each criterion had the attached scores.
There was a total of 70 criteria with a total score of 100 and 3 levels of
evaluation: 1) No exploitation description: 0% points; 2) incomplete
descriptive exploitation: 50% points; 3) Enough description: 100% points.
The score of each content and the whole of IMR was converted into a 10point scale and compared with the classification of the "Regulation on the

regular training of universities and colleges according to the credits system” by


Decision 43/2007/QD-BGDDT of the Ministry of Education and Training
issued. The score of MRMS that meets the set requirements is ≥ 5.5 scores,
fairly good is ≥ 7 scores.
2.6. Data process and analysis
The data of the research were checked, cleaned, coded, and entered into
the Epidata 3.1 software and then was processed with the Stata 11.0 software.
The research indicators were computed as frequency, percentage, average and
standard deviations. The Chi2 and T-student test statistics were used to compare
the difference in proportions and averages between the two research groups,
statistically significant when p <0.05. Using logistics analysis to find the
relationship between the results of MRMS and CP results. The results of
qualitative research were summarized and presented opinion boxes to
supplement quantitative research results.
2.7. Ethics in research
The project complied with the ethical regulations in biomedical
research. This research was supported by university leaders, CP facilities,
lecturers, and students. The research did not affect the rights, honor, and
health of the subjects.
2.8. Errors and error control
Designing the easy-to-understand questionnaire and conducting a pilot
survey of the questionnaire before collecting official data. Selecting and training
of investigators carefully; to supervise the process of assessing the MR and
datas.
CHAPTER 3. RESEARCH RESULTS
3.1. The situation of infectious CT for medical students at VMU
3.1.1. Actual situation of infectious CT of lecturers
- Lecturers with an average age of 33 ± 7.5; Doctors accounted for

88.9%, with the postgraduate qualification of 40.7%. Lecturers had worked
for 10 years or more accounted for 25.9%. Participated in CT for more than 5
years was 37.0%. Only 26.0% of the lecturers were seft-confident in CT for
medical students.
- The percentage of lecturers who regularly prepared the CT content
for students was not high. The activity "regular, periodic monitoring of CP
activities of students" had the lowest rate of 14.8%. However, 89.9% of
lecturers regularly gave students access to the MR to study.
- The form of CT: 92.6% lecturers applied the form of "teaching by the
bedside" and rated the form of "MRC" as the most effective and appropriate,
respectively 55.6% and 51.9%.
- For students' MRMS: the majority of lecturers rated that the normal
level, accounting for 74.1%. 51.9% of lecturers said that it was necessary to
strengthen their skills of "history and pre-history exploitation" and 55.6% of


lecturers rated the CP results of students as accurate.
- The percentge of lecturers who found it necessary to apply IT in
teaching accounted for a high proportion (92.6%). 74% of lecturers agreed
that MRC/case discussions should applied IT.
3.1.2. The situation on the infectious CP of medical students
- The rate of female students was 65.1%; non-religious was 95.1%,
Kinh ethnic group accounted for 76%; 44.8% of students practiced clinically
at the Department of Tropical Diseases - Provincial General Hospital.
- Evaluation of the content of the training program: 38.7% of students
thought that the content of "assigning professional criteria in CP" accounted
for the lowest rate. 94.3% of students noted that they have been informed of
the clinical training schedule from the Training Department.
- Evaluation of CT forms: 83.9% of students rated the form of
“teaching by the bedside” was applied and 49.9% of the students considered

the MRC, case discussion as the best-fit form.
- Assessing the advantages and disadvantages of CP: only 30.0% of the
students thought that there was the attention and helping of lecturers; while
83.1% of the students said that the difficulty was the lack of CT staff.
80
70
60
50
40
30
20
10
0

74.1

45.2
29.7
16.1
7.1
Lack of Lack of skills Lack of
Lack of
Not enough
theoretical
to ask
clinical
patients and time to make
knowledge
questions, teaching staff, uncooperative medical
about the

examine,
mentoring,
patients
records
disease
communicate supervision

Figure 3.4: Students assessed difficulties in making medical record (n =
367)
Comment: 74.1% of students said that "lack of clinical lecturers,
mentoring, supervision" was the main difficulty in MRMS. Lack of skills in
asking, examing, communicating was accounted for 45.2%.
- The need for IT applications: 95.6% of students saw the desire to
apply IT in CT. 85.6% of the students said that using MRC was an


appropriate form to apply IT. 85.8% of students needed to use the EMR.
3.1.3. The situation of human resources, facilities, and training programs for
CT
CP facilities were relatively adequate with manpower and facilities for
CT. However, the number of lecturers with postgraduate qualifications was
still low. Patient flow and the disease structure at Military Medical Hospital
4 were inadequate. The training program to ensure basic CT was fully
prepared. The number of implementation of the MRC was 6-8 times/batch.
3.2. The effectiveness of intervention by the EMR
3.2.1. The effectiveness of intervention through the assessment of MRMS
- Comparison of the skill of exploitating the administrative information
before, after the intervention, and compared with the control group: Before
the intervention, the average score of administrative information
exploitation skills of both intervention and control groups was medium.

After the intervention, the average score of the intervention group increased
by 0.2 points (p <0.05), while the control group increased by 0.1 points (p>
0.05).
- Comparison of the skill of exploitating the reasons for the
hospitalization before, after the intervention and compared with the control
group: after the intervention, the average score of the skill of exploiting the
reason for admission to the hospital in the intervention group increased by
1.3 points (p < 0.05), while the control group increased by 0.2 points (p>
0.05).
- Comparison of the skill of historic exploitation before, after the
intervention, and compared with the control group: The difference in scores
after intervention between the control group and the intervention group was
1.9 points, the difference was statistically significant with p <0.05. The
difference in scores before and after intervention in the intervention group
increased by 2.4 points (p <0.05), while this difference in the control group
was 0.1 points (p> 0.05).
- Comparison of skill of pre-historic exploitation before, after the
intervention, and compared with the control group: After the intervention,
the average score of pre-history exploiting skill of the intervention group
increased by 0.4 points, while the control group increased by 0.3 points. The
difference was statistically significant (p<0.05). The difference between the
intervention and control group was 0.8 points, the difference was
statistically significant (p<0.05).
- Comparison of skill of physical examination before, after the
intervention, and compared with the control group: The difference in points
after intervention between the control group and the intervention group was
1.9 points. The difference between the points pre-intervention and post-


intervention in the intervention group increased by 3.3 points, while the

difference in the control group was 0.4 points, the difference was statistically
significant (p <0.05).
- Comparison of skills of summary of MR and preliminary diagnosis
before, after the intervention, and compared with the control group: The
difference in the score at the time of pre-intervention between the control group
and the intervention group was 0.5 points, the difference was significant with p
<0.05; the difference after intervention between the control group and the
intervention group was 1.4 points, the difference is statistically significant with p
<0.05.
- Comparison of the skills of proposal of subclinical testings before, after
the intervention, and compared with the control group: after the intervention,
the average score of the intervention group increased by 1.2 points, the
difference was statistically significant, while the control group even decreased
by 0.3 points (p> 0.05).
- Comparison of skills of reasoning and definite diagnostic before,
after the intervention, and compared with the control group: The difference
in the score at the time of pre-intervention between the control group and the
intervention group was 0.2 points, the difference was not statistical
significance with p> 0.05; the difference after intervention between the
control group and intervention group was 1.4 points, the difference was
statistically significant with p <0.05.
- Comparison of the skill of treatment disease before, after the
intervention, and compared with the control group: after the intervention, the
average score of the intervention group increased by 1.4 points, the difference
was statistically significant, while the control group increased by 0.3 points (p
<0.05).
- Comparison of the skill of the prognosis disease before, after the
intervention, and compared with the control group: The difference the score
at the time of after intervention between the control group and the intervention
group was 0.5 points, the difference was statistically significant with p <0.05;

after the intervention, the score of the intervention group increased by 0.8
points, while the control group was 0.6 points, the difference was statistically
significant.
- Comparison of the skills of prevention, health education before, after
the intervention, and compared to the control group: The difference before
and after the intervention in the intervention group increased by 0.9 points,
the difference was statistically significant with p <0.05. The difference in
the score at the time of after intervention between the intervention group and
the control group was 1.3 points, the difference was statistically significant
with p <0.05.
- Assess the CP results of the students after the intervention compared


to the control group: after the intervention, the fairly good results of the
intervention group was 6.3 times higher than the control group, the
difference was statistically significant with p <0.05.
Table 3.32: The intervention effectiveness by EMR to improve
MRMS
Efficiency Index
(%)
p
Medical record-making
(t Control Interventio IE (%)
skill
test)
group
n group
(n = 156)
(n =152)
Exploiting the administrative

2.7
5.4
2.7
0.23
information
Exploiting the reasons for
5.4
46.4
41.0
< 0.00
hospitalization
Historic exploitation
1.1
27.3
26.2
< 0.00
Pe-historic exploitation
6.8
7.8
1.0
0.74
Physical examination
4.3
39.8
35.5
< 0.00
Summary of MR and
1.6
14.9
13.3

< 0.00
preliminary diagnosis
Proposal for subclinical
3.8
15.2
11.4
0.00
testing
Reasoning, definite diagnosis
1.7
30.4
28.7
< 0.00
Treatment of disease
5.5
26.4
20.9
< 0.00
Prognosis of disease
20.7
25.0
4.3
0.4
Prevention, health education
5.9
40.9
35.0
< 0.00
Comments: The results of the table showed that the skill of “exploiting
the reasons for hospitalization” had the highest IE (41.0%) with p<0.05.

Skills of “exploiting the administrative information”, “Historic
exploitation”, “Prognosis of diseases” had low IE and not statistically
significant (p> 0.05).
Table 3.33. The relationship between the results of clinical teaching
process and MRMS in the intervention group (n = 152)
Results of CP process
OR
Fairly
medium,
Results of the MRMS
(95 %
p
good
weak
CI)
n
%
n
%
Exploiting
Fairly good
7
61.8 4 38.2
2.0
0.09
the
6
7
(0.8 - 4.6)
6

administrativ medium,
1
44.8 1 55.2
e information weak
3
6
Exploiting
Fairly good
8
60.0 5 40.0
3.8
0.1
the reasons
7
8
(0.7 - 20.4)
for
medium,
2
28.6 5 71.4
hospitalizatio weak


n
Historic
exploitation
Pe-historic
exploitation
Physical
examination

Summary of
MR and
preliminary
diagnosis
Proposal for
subclinical
testing

Fairly good
medium,
weak
Fairly good
medium,
weak
Fairly good
medium,
weak
Fairly good
medium,
weak
Fairly good

2
5
6
4
3
7
5
2

8
5
4

86.2

4

13.8

52.0

5
9
2

48.0

6
1
5
4
9

54.0

8
0
9

71.4

3
2
3
1

28.6

8
5
4

63.9

94.8
46.0
61.2
30.8

22.5

5.2

38.9

5.8
(1.8 - 18.4)

0.00

1

21.7
(4.2111.5)

0.00

3.5
(1.0 - 12.3)

0.03
4

8.6
(3.3 - 22.2)

0.00

69.2

77.5

4 36.1
6.6
0.00
8
(1.9 - 22.3)
04
medium,
21.1 1 78.9

weak
5
Reasoning,
Fairly good
7
75.3 2 24.7
8.9
0.00
definite
6
5
(3.6 - 21.5)
diagnosis
medium,
1
25.5 3 74.5
weak
3
8
Treatment of Fairly good
4
82.8 1 17.2
6.2
0.00
disease
8
0
(2.6 -14.7)
Medium,
4

43.6 5 56.4
weak
1
3
Prognosis of
Fairly good
8
61.9 5 38.1
5.4
0.00
disease
6
3
(1.4 - 21.3)
7
medium,
3
23.1 1 76.9
weak
0
Prevention,
Fairly good
8
70.7 3 29.3
10.0
0.00
health
2
4
(3.6 -27.9)

education
medium,
7
19.4 2 80.6
weak
9
Comments: There was a relationship between the results of CP process
and some MRMS with p <0.05: Historic exploitation skill (OR = 5.8; 95 %
CI: 1.8 - 18.4); Pre-historic exploitation skill (OR = 21.7; 95 % CI: 4.2-111.5);
Physical Examination Skill (OR = 3.5; 95 % CI: 1.0 - 12.3); Summary of MR
and preliminary diagnosis skills (OR = 8.6; 95 % CI: 3.3 - 22.2); Proposal for


subclinical testing Skill (OR = 6.6; 95 % CI: 1.9 - 22.3); Reasoning, definite
diagnosis skill (OR = 8.9; 95 % CI: 3.6 - 21.5); Treatment of disease skill (OR
= 6.2; 95 % CI: 2.6 -14.7); Prognosis of disease skill (OR = 5.4; 95 % CI: 1.4 21.3); Prevention, health education skill (OR = 10; 95 % CI: 3.6 -27.9). There
was no statistically significant relationship between CP results and results in
contents: Exploitation of the administrative information and Exploiting the
reasons for hospitalization (with p> 0.05).
3.2.2. Students self-assessed the adequacy of the MRMS after the
intervention
Table 3.34: Students self-assessed the adequacy of exploitation of the
medical after the intervention (n = 152)
Exploitation level
Contents
Adequate
Inadequate
(%)
(%)
Exploiting the administrative

90.0
10.0
information
Exploiting the reasons for hospitalization
81.1
19.9
Historic exploitation
78.0
22.0
Pe-historic exploitation
79.2
21.8
Physical examination
78.4
21.6
Summary of MR and preliminary diagnosis
73.6
26.4
Proposal for subclinical testing
60.7
39.3
Reasoning, definite diagnosis
71.8
29.2
Treatment of disease
75.4
24.6
Prognosis of disease
74.4
25.6

Prevention, health education
76.9
23.1
Comment: Students self-assessed at the highest adequate level in the
content "Exploiting the administrative information" with the rate of 90.0%
and the lowest in the content "Proposal for subclinical testing" with the rate
of 60.7%.
3.2.3. Student feedback on the E-learning course “Guideline for making
the IMR” and application of EMR
- Feedback on "Objectives and content of the course": The percentage
of students who responded to this issue accounted for a high rate from
81.6% to 93.4%. However, 5.9% of students disagreed when responding to
"The length of the course is sufficient for students to practice the content".
- Feedback on "Organization and management of the course": The
percentage of students who agreed with this content accounted for 87.5% to
95.4%. The content of "Students are satisfied with the mentoring support of
lecturers during the learning process" reached the highest rate of agreement.
- Feedback on "Training method in the course": The percentage of
students agreed with the content accounted for a high rate from 88.2% to
95.4%. Among the content, students agreed with the content of "Lecturers
have an open mind and respect the opinions of students" had the highest rate


of agreement.
- Feedback on "Methods of examination and evaluation": The
percentage of students agreeing with this content accounted for a high rate
from 88.2% to 94.1%. Students agreed with the content of “The method of
grading MR is suitable to the learning objectives” with the highest rate
(94.1%).
- Feedback on "Facilities, equipments, teaching materials": the percentage

of students agreeing with the content accounted for the proportion from 89.5%
to 94.1%.
- Feedback on "Effect of the course": The percentage of students
agreeing with the content accounted for 92.1% to 94.7%. The section "The
course has supported the development of professional knowledge and skills
for students' careers" accounted for the highest rate (94.7%).
- Feedback on the most satisfactory thing of the course: Most of the
students thought that the courses and EMR gave students new thinking of
MRMS. IT applications improved knowledge and professional skills.
- Feedback on the dissatisfaction of the course: the course was short,
required the Internet and smart devices. Students were not proficient in IT.
Besides, it was still surprising, inconvenient when using in the patient’s
chamber and the interaction of members was not much.
- Feedback on the advantages of applying IT to improve MRMS: Most
students rated the advantages as fast; full; accessible; easy access; good
storage; economical, and appropriate in learning trends today.
- Feedback on replicating the course model: The majority of students
agreed and wished to replicate the course model. They also thought that the
course and EMR should be applied early to students when starting CP.
3.2.4. Feedback from university leaders, managers, and lecturers on the
EMR
100% of the participants in the discussion agreed to accept the deployment
and application of EMR. Summary of the opinions' members:
- Opinions of university leaders, managers, lecturers on the urgency
and significance of the use of the EMR: The members all recognize the
urgency and significance of the EMR to help to solve the lack of clinical
lecturers, fitted educational trends, increased the interaction of lecturers with
students, and improved training effectiveness.
- Opinions of university leaders, managers, lecturers on the form of the
EMR: Most of the discussion members noted that the form of EMR was

simple, easy to understand, easy to see, and easy to interact.
- Opinions of university leaders, managers, lecturers on the structure
of the EMR: Most of the participants assessed the EMR was adequate
contents of the MR, arranged the order, and used the appropriate selection
techniques.
- Opinions of university leaders, managers, lecturers on the accuracy of
science about terminology and updates of the EMR: Most of the opinions’
members ensured that the EMR was updating, accurate, reliable, and appropriate
with infectious subjects.


- Opinions of university leaders, managers, lecturers about the
suitability when deploying and applicating the EMR for CT: the majority of
members identified that the EMR was suitable for the university's
conditions, training subjects, training regulations, and educational trends.
- Opinions of university leaders, managers, lecturers on the conditions
to deploy and applicate the EMR for CT: Most of the members' opinions
evaluated the feasibility of the current conditions' university, supported the
deployment of EMR, and encouraged lecturers to apply.
CHAPTER 4. DISCUSSION
4.1. The research results of situation of clinical teaching of infectious
subjects for medical students at Vinh medical University
4.1.1. The actual situation of lectures staff with clinical teaching activity
Research results of lecturers staff showed that: the average age was 33
± 7.5. The lecturers was a relatively young and suitable for teaching,
creating, innovating, easily accessing, and developing new things in
teaching methods. The rate of lecturers are doctors accounted for 88.9%.
The high percentage of doctors is those who have appropriate qualifications
for CT for medical students. Qualifications, clinical experience, ethics as
well as the doctor's working style are sources of knowledge that students

need to exploit and follow during CP. However, subjects with postgraduate
qualifications only accounted for 40.7%. This also causes difficulties in
teaching and poses a problem for the universiyt in the development of
postgraduate teaching staff. Thus, compared with Pham Thi Hanh's research,
the number of lecturers with postgraduate qualifications was still low in
VMU.
The survey on CT showed that 89.9% of lecturers thought that they
often helped and created favorable conditions for students to access facilities
and MR to study. However, only 14.8% of lecturers had the regular
monitoring of CP activities of students. This was explained by the fact that
most of lecturers were more interested in CT contents than CT plans.
Lecturers also had the limited time so the activities of monitoring
periodically CP of students were not often.
Regarding the form of CT: the majority of lecturers (92.6%) thought that
“the teaching by the bedside” was the main form being applied. The form of
"MRC/case discussion" was the form rated by lecturers as the most effective
(55.6%) and the most suitable for CP at facilities (51.9%). Pham Thi Hanh's
research at Hai Phong University of Medicine and Pharmacy showed that:
4th-year students used the bedside-study method, the bedside-study method
combined with the case discussion at the regular level were 81.5% and 78.4%.
Research results of Nguyen Duc Linh and colleagues at Tay Nguyen
University showed that the percentage of students who attended the briefings
(68.8%), studied at the bedside (97.6%). Thus, the comparison of CT form
with other universities, we found that it was similar.
74.1% of lecturers rated that the students' MRMS were normal and nogood. The percentage of lecturers also said that the MRMS of students needs
to be strengthened were: historic and pre-historic exploitation; physical