A Study of the Difference in Volume of Information in Chief Complaint and Present Illness between Electronic and Paper Medical Records

Abstract

The introduction of an electronic medical record (EMR) has been rapidly accelerating in South Korea. The EMR was expected to improve quality of care, readability, availability, and the quality of data. However, the reluctance of healthcare providers to use the EMR may have caused a reduction of information recorded in EMRs. The purpose of this study was to identify whether there was any loss of information following the introduction of a narrative text-based EMR in the recording of chief complaint and present illness in inpatient medical records. Inpatient medical records of a university hospital were retrospectively evaluated for one month before and one month after the introduction of the EMR in June 2006. The volume of information for chief complaint and present illness was measured by number of words in Korean and normalised bytes. Change in volume of information was measured by two-way ANOVA and multiple regression analyses, controlling for doctors' gender, age, and grade/year of residents, patients' readmission status, reasons for admission and service department to assess any effect of the introduction of an EMR. Total numbers of paper-based medical records (PMRs) and EMRs for analysis were 1,159 and 1,122, respectively. Forty-three doctors participated in the study. Thirty-one (72%) doctors were less than 30 years of age. Number of words proved a better outcome measure (R²=.22 for CC, R²=.36 for PI) than normalised bytes (R²=.18 for CC, R²=.35 for PI) for measuring volume of information. Results showed that the volume of information in the chief complaint and present illness was not decreased after the introduction of the EMR, except when the dependent variable was measured by number of words in the present illness. The study showed that the introduction of the EMR did not reduce the volume of information documented for chief complaint and present illness in inpatient medical records. However, further studies are needed to identify how to control the probable loss of information as showed in present illness measured by number of words.

Keywords

Electronic Medical Records Electronic Clinical Documentation Hospital Information Systems Evaluation Quality of Health Care Medical Record Systems Computerised Health Information Management

Get full access to this article

View all access options for this article.

References

Adams

W.G.

Mann

A.M.

Bauchner

(2003). Use of an electronic medical record improves the quality of urban pediatric primary care. Pediatrics 111: 626–32.

Andrew

W.F.

Dick

R.S.

(1995). Applied information technology: A clinical perspective. Feature focus: The computer-based patient record (Part 2). Computers in Nursing 13: 118–22.

Apkon

Singhaviranon

(2001). Impact of an electronic information system on physician workflow and data collection in the intensive care unit. Intensive Care Medicine 27: 122–30.

Branger

P.J.

van't Hooft

van der Wouden

J.C.

Duisterhout

J.S.

van Bemmel

J.H.

(1998). Shared care for diabetes: Supporting communication between primary and secondary care. Studies in Health Technology and Informatics 52(1): 412–6.

Callen

J.L.

Alderton

McIntosh

(2008). Evaluation of electronic discharge summaries: A comparison of documentation in electronic and handwritten discharge summaries. International Journal of Medical Informatics 77: 613–620.

Chae

Y.M.

(2005). Report on Hospital Information System Survey. Journal of Korean Society of Medical Informatics 11: 323–336.

Chaudhry

Wang

Maglione

Mojica

Roth

Morton

S.C.

Shekelle

P.G.

(2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine 144: 742–52.

Chiang

M.F.

Cao

Sharda

Hripcsak

Starren

J.B.

(2003). An experimental system for comparing speed, accuracy, and completeness of physician data entry using electronic and paper methods. AMIA Annual Symposium Proceedings: 812.

Dick

Steen

Detmer

(1997). The computer-based patient record: An essential technology for health care. National Academies Press, Washington, DC.

10.

Embi

P.J.

Yackel

T.R.

Logan

J.R.

Bowen

J.L.

Cooney

T.G.

Gorman

P.N.

(2004). Impacts of computerized physician documentation in a teaching hospital: Perceptions of faculty and resident physicians. Journal of the American Medical Informatics Association 11: 300–9.

11.

Gilbert

J.A.

(1998). Physician data entry: Providing options is essential. Health Data Management 6: 84–6, 88, 90–2.

12.

Hamilton

W.T.

Round

A.P.

Sharp

Peters

T.J.

(2003). The quality of record keeping in primary care: A comparison of computerised, paper and hybrid systems. British Journal of General Practice 53: 929–33; discussion 933.

13.

Hammond

Helbig

Benson

Brathwaite-Sketoe

(2003). Are electronic medical records trustworthy? Observations on copying, pasting and duplication. AMIA Annual Symposium Proceedings 2003: 269.

14.

Jha

A.K.

Desroches

C.M.

Campbell

E.G.

Donelan

Rao

S.R.

Ferris

T.G.

Shields

Rosenbaum

Blumenthal

(2009). Use of electronic health records in U.S. hospitals. The New England Journal of Medicine 360: 1628–38.

15.

Jha

A.K.

Doolan

Grandt

Scott

Bates

D.W.

(2008). The use of health information technology in seven nations. International Journal of Medical Informatics 77: 848–54.

16.

Johnson

K.B.

Cowan

(2002). Clictate: A computer-based documentation tool for guideline-based care. Journal of Medical Systems 26: 47–60.

17.

Kanegaye

J.T.

Cheng

J.C.

McCaslin

R.I.

Trocinski

Silva

P.D.

(2005). Improved documentation of wound care with a structured encounter form in the pediatric emergency department. Ambulatory Pediatrics 5: 253–7.

18.

Kaplan

(1994). Reducing barriers to physician data entry for computer-based patient records. Topics in Health Information Management 15: 24–34.

19.

H.G.

Newmark

L.P.

Yoon

Volk

L.A.

Carlson

V.L.

Kittler

A.F.

Lippincott

Wang

Bates

D.W.

(2007). Electronic health records in specialty care: A time-motion study. Journal of the American Medical Informatics Association 14: 609–15.

20.

McDonald

C.J.

(1997). The barriers to electronic medical record systems and how to overcome them. Journal of the American Medical Informatics Association 4: 213–21.

21.

Mikkelsen

Aasly

(2000). Concordance of information in parallel electronic and paper based patient record. International Journal of Medical Informatics 63:123–31.

22.

O'Connell

R.T.

Cho

Shah

Brown

Shiffman

R.N.

(2004). Take note(s): Differential EHR satisfaction with two implementations under one roof. Journal of the American Medical Informatics Association 11: 43–9.

23.

Patel

V.L.

Arocha

J.F.

Kushniruk

A.W.

(2002). Patients' and physicians' understanding of health and biomedical concepts: Relationship to the design of EMR systems. Journal of Biomedical Informatics 35: 8–16.

24.

Patel

V.L.

Kushniruk

A.W.

Yang

Yale

J.F.

(2000). Impact of a computer-based patient record system on data collection, knowledge organization, and reasoning. Journal of the American Medical Informatics Association 7: 569–85.

25.

Retchin

S.M.

Wenzel

R.P.

(1999). Electronic medical record systems at academic health centers: Advantages and implementation issues. Academic Medicine 74: 493–8.

26.

Rosenbloom

S.T.

Kiepek

Belletti

Adams

Shuxteau

Johnson

K.B.

Elkin

P.L.

Shultz

E.K.

(2004). Generating complex clinical documents using structured entry and reporting. Studies in Health Technology and Informatics 107: 683–687.

27.

Roukema

Los

R.K.

Bleeker

S.E.

Van Ginneken

A.M.

Van Der Lei

Moll

H.A.

(2006). Paper versus computer: Feasibility of an electronic medical record in general pediatrics. Pediatrics 117: 15–21.

28.

Shiffman

R.N.

Brandt

C.A.

Freeman

B.G.

(1997). Transition to a computer-based record using scannable, structured encounter forms. Archives of Pediatrics & Adolescent Medicine 151: 1247–53.

29.

Stausberg

Koch

Ingenerf

Betzler

(2003). Comparing paper-based with electronic patient records: Lessons learned during a study on diagnosis and procedure codes. Journal of the Medical Informatics Association 10: 470–477.

30.

Tang

P.C.

Larosa

M.P.

Gorden

S.M.

(1999). Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. Journal of the American Medical Informatics Association 6: 245–51.

31.

Treweek

(2003). The potential of electronic medical record systems to support quality improvement work and research in Norwegian general practice. BMC Health Services Research 3: 10.

32.

Tsai

Bond

(2008). A comparison of electronic records to paper records in mental health centers. International Journal for Quality in Health Care 20: 136–43.

33.

Williams

Boren

S.A.

(2008). The role of the electronic medical record (EMR) in care delivery development in developing countries: A systematic review. Informatics in Primary Care 16: 139–45.

34.

Wright

McGlinchey

E.A.

Poon

E.G.

Jenter

C.A.

Bates

D.W.

Simon

S.R.

(2009). Ability to generate patient registries among practices with and without electronic health records. Journal of Medical Internet Research 11: e31.