Comparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure...

Area of Science:

• Health Informatics
• Medical Record Management
• Comparative Effectiveness Research

Background:

• Paper-based and electronic patient records are concurrently utilized, each serving distinct functions.
• Existing comparative studies often lack methodological rigor and patient-centric perspectives, frequently treating paper records as the benchmark.

Purpose of the Study:

• To compare the quality and content of paper-based patient records (PPR) and electronic patient records (EPR) for surgical patients.
• To evaluate potential unique advantages of both record types based on specific quality criteria.

Main Methods:

• A comparative analysis of diagnosis and procedure codes was conducted between EPR and PPR sets for surgical patients at a non-university hospital.
• Data extraction and transformation from PPR to facilitate comparison with EPR were performed by a single individual, a common but noted limitation.

Main Results:

• Paper-based patient records demonstrated minor qualitative advantages in diagnosis coding.
• Electronic patient records exhibited potential improvements in both the quality and quantity of procedure coding.
• The study supports the complementary nature of paper and electronic records.

Conclusions:

• Medical professionals should acknowledge potential discrepancies between paper and electronic health information.
• Integrating information from both PPR and EPR is recommended to ensure comprehensive patient data.
• Methodological improvements are crucial for future studies comparing paper and electronic health records to enhance generalizability and reproducibility.