Electronic health records improve clinical note quality

Abstract

Background and objective The clinical note documents the clinician's information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes.Materials and methods A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes.Results The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval.Conclusions The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.

Two years of unintended consequences: introducing an electronic health record system in a hospice in Scotland

“…Burke et al . () offer further evidence of change requiring a longer‐term perspective. They examined the impact over five‐and‐a‐half years and their conclusion is one of the most positive endorsements of EHRs in the literature.…”

“…EHRs improved the quality of notes according to a large study by Burke et al . (). Because patients should not have to repeat routine information, EHRs should therefore improve both cost‐effectiveness and the patient experience (Boonstra et al .…”

Completude das informações do registro hospitalar de câncer em um hospital de Florianópolis

“…Para tal, no ano de 2002, o Conselho Federal de Medicina editou a Resolução n º 1.638, passando a exigir a criação de comissões de revisão de prontuários, às quais competem: a observação dos itens que são obrigatórios nos prontuários, a garantia da legibilidade da letra em prontuários manuais e a responsabilidade do preenchimento, armazenamento e manuseio dos referidos documentos 29 . Nesse sentido, a melhoria da qualidade do registro em saúde, mediante o incentivo à estruturação da chamada "informática médica", com fichas eletrônicas padronizadas provendo campos obrigatórios que facilitem a coleta de informações essenciais aos serviços de saúde, tem como finalidade aperfeiçoar o armazenamento, a recuperação e o gerenciamento dessas informações 19,30,31 . Estudos pontuam que a aplicação de protocolos eletrônicos ainda é limitada devido aos custos dos equipamentos para implementação e manutenção, à falta de mão de obra qualificada e à possível resistência dos profissionais ao uso da informática 27,32 .…”

Using health-system-wide data to understand hepatitis B virus prophylaxis and reactivation outcomes in patients receiving rituximab

“…This approach eliminated prevalent users from the sample, who might plausibly have less documentation of screening tests; and mitigated the possible effects of a new EHR reducing complete documentation and ordering. [27] …”