JMIR Publications

ABSTRACT

Background:

Electronic medical records (EMR) are considered a key component of the health care systems digital transformation. The implementation of an EMR promises various improvements e.g. in the availability of information, coordination of care, or patient safety and is required for big data analytics. To ensure those possibilities of an EMR, the included documentation must be of high quality. In this matter, the most frequently described dimension of data quality is the completeness of documentation. In this regard, little is known about how and why the completeness of documentation might change after the implementation of an EMR.

Objective:

The purpose of the presented study is to compare the completeness of documentation in paper-based medical records and electronic medical records and to discuss the possible impact of an EMR on the completeness of documentation.

Methods:

A retrospective document analysis was conducted, comparing the completeness in paper-based medical records and EMRs. Data were collected before and after implementation of an EMR on an orthopaedical ward in a German academic teaching hospital. The anonymized records represent all treated patients of a three-week period each. Unpaired, two tailed t-tests, χ²-tests and Odds Ratios were calculated to analyze and compare the mean completeness of the two record types in general and of ten specific items in detail (blood pressure, body temperature, diagnosis, diet, excretions, height, pain, pulse, reanimation status, weight). For this purpose, each of the ten items received a score of 1 if it was documented on the day of admission, otherwise it was scored as 0.

Results:

N=180 medical records became part of the analysis. The average completeness was 6.25 (SD 2.15) out of 10 in the paper-based medical record, significantly rising to an average of 7.13 (SD 2.01) in the EMR (t(178)=-2.469; P=.014; d=-0.428). When looking at the significant changes of the ten items in detail, the documentation of diet (P<.001), height (P<.001) and weight (P<.001) was more complete in the EMR, while the documentation of diagnosis (P<.001), excretions (P=.016), and pain (P=.008) was less complete in the EMR. The completeness remained significantly unchanged for the documentation of pulse (P=.276), blood pressure (P=.474), body temperature (P=.497) and reanimation status (P=.729).

Conclusions:

Implementing EMRs can influence the completeness of documentation with a possible change to both, an increased or decreased completeness. However, the mechanisms that determine those changes are often neglected. There are mechanisms that might facilitate an improved completeness of documentation and could relieve or increase the staffs’ burden, caused by documentation tasks. Research is needed to take advantage of these mechanisms and use them for mutual profit in the interests of all stakeholders. Clinical Trial: The project is registered at the German clinical trials register (DRKS00023343).