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.

The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals—A Systematic Review

“…Although the hospital setting was an inclusion criterion, the hospital setting still varies. There are differences in specialty (e.g., burn unit or orthopedic surgical ward) [ 13 , 14 ], size (e.g., 700 beds or 1,200 beds) [ 15 , 16 ], academical teaching activity, and one hospital which was not further specified [ 17 ]. Derived from that, all included studies investigate the documentation through the lens of a certain use case like for example operation reports or discharge instructions [ 14 , 18 ].…”

“…The most commonly analyzed outcomes were completeness [ 15 , 17 , 20 , 21 , 23 , 25 , 26 ], guideline adherence [ 13 , 14 , 18 , 22 ], and volume of documentation [ 11 , 16 , 17 , 19 ]. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation.…”

“…All other studies did not use any validated instrument to measure their outcomes. Moreover, several studies did not define their outcomes [ 16 , 19 , 24 ], or did so only superficially [ 21 ]. None of the studies followed a theoretical framework.…”

Comparison of Documentation Quality using Electronic Nutrition Care Process (NUCAPRO) and Manual System

“…In manual system, incompleteness found in nutritional status interpretation. Previous study show that the weakness of manual system was incomplete documentation result to quality of health service [9]. Incomplete information leading to delay or error in decision making [10].…”