The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis
BackgroundElectronic medical records (EMR) are considered a key component of the health care system’s digital transformation. The implementation of an EMR promises various improvements, for example, in the availability of information, coordination of care, or patient safety,...
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| Format: | Article |
| Language: | English |
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JMIR Publications
2024-01-01
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| Series: | JMIR Medical Informatics |
| Online Access: | https://medinform.jmir.org/2024/1/e47761 |
| _version_ | 1797351298230648832 |
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| author | Florian Wurster Marina Beckmann Natalia Cecon-Stabel Kerstin Dittmer Till Jes Hansen Julia Jaschke Juliane Köberlein-Neu Mi-Ran Okumu Carsten Rusniok Holger Pfaff Ute Karbach |
| author_facet | Florian Wurster Marina Beckmann Natalia Cecon-Stabel Kerstin Dittmer Till Jes Hansen Julia Jaschke Juliane Köberlein-Neu Mi-Ran Okumu Carsten Rusniok Holger Pfaff Ute Karbach |
| author_sort | Florian Wurster |
| collection | DOAJ |
| description |
BackgroundElectronic medical records (EMR) are considered a key component of the health care system’s digital transformation. The implementation of an EMR promises various improvements, for example, in the availability of information, coordination of care, or patient safety, and is required for big data analytics. To ensure those possibilities, 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.
ObjectiveThis study aims to compare the completeness of documentation in paper-based medical records and EMRs and to discuss the possible impact of an EMR on the completeness of documentation.
MethodsA retrospective document analysis was conducted, comparing the completeness of paper-based medical records and EMRs. Data were collected before and after the implementation of an EMR on an orthopaedical ward in a German academic teaching hospital. The anonymized records represent all treated patients for a 3-week period each. Unpaired, 2-tailed t tests, chi-square tests, and relative risks were calculated to analyze and compare the mean completeness of the 2 record types in general and of 10 specific items in detail (blood pressure, body temperature, diagnosis, diet, excretions, height, pain, pulse, reanimation status, and weight). For this purpose, each of the 10 items received a dichotomous score of 1 if it was documented on the first day of patient care on the ward; otherwise, it was scored as 0.
ResultsThe analysis consisted of 180 medical records. 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 (t178=–2.469; P=.01; d=–0.428). When looking at the significant changes of the 10 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=.02), and pain (P=.008) was less complete in the EMR. The completeness remained unchanged for the documentation of pulse (P=.28), blood pressure (P=.47), body temperature (P=.497), and reanimation status (P=.73).
ConclusionsImplementing EMRs can influence the completeness of documentation, with a possible change in both increased and 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 decrease or increase the staff’s 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.
Trial RegistrationGerman Clinical Trials Register DRKS00023343; https://drks.de/search/de/trial/DRKS00023343 |
| first_indexed | 2024-03-08T12:58:14Z |
| format | Article |
| id | doaj.art-7939378971ff4d349566be59ad905bc9 |
| institution | Directory Open Access Journal |
| issn | 2291-9694 |
| language | English |
| last_indexed | 2024-03-08T12:58:14Z |
| publishDate | 2024-01-01 |
| publisher | JMIR Publications |
| record_format | Article |
| series | JMIR Medical Informatics |
| spelling | doaj.art-7939378971ff4d349566be59ad905bc92024-01-19T14:45:32ZengJMIR PublicationsJMIR Medical Informatics2291-96942024-01-0112e4776110.2196/47761The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document AnalysisFlorian Wursterhttps://orcid.org/0000-0001-5527-9238Marina Beckmannhttps://orcid.org/0000-0002-9826-3575Natalia Cecon-Stabelhttps://orcid.org/0000-0002-2548-5986Kerstin Dittmerhttps://orcid.org/0000-0003-3390-1377Till Jes Hansenhttps://orcid.org/0000-0001-6175-7670Julia Jaschkehttps://orcid.org/0000-0003-3424-2588Juliane Köberlein-Neuhttps://orcid.org/0000-0002-3451-7847Mi-Ran Okumuhttps://orcid.org/0000-0002-9301-8829Carsten Rusniokhttps://orcid.org/0000-0002-5383-4549Holger Pfaffhttps://orcid.org/0000-0001-9154-6575Ute Karbachhttps://orcid.org/0000-0003-3479-9474 BackgroundElectronic medical records (EMR) are considered a key component of the health care system’s digital transformation. The implementation of an EMR promises various improvements, for example, in the availability of information, coordination of care, or patient safety, and is required for big data analytics. To ensure those possibilities, 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. ObjectiveThis study aims to compare the completeness of documentation in paper-based medical records and EMRs and to discuss the possible impact of an EMR on the completeness of documentation. MethodsA retrospective document analysis was conducted, comparing the completeness of paper-based medical records and EMRs. Data were collected before and after the implementation of an EMR on an orthopaedical ward in a German academic teaching hospital. The anonymized records represent all treated patients for a 3-week period each. Unpaired, 2-tailed t tests, chi-square tests, and relative risks were calculated to analyze and compare the mean completeness of the 2 record types in general and of 10 specific items in detail (blood pressure, body temperature, diagnosis, diet, excretions, height, pain, pulse, reanimation status, and weight). For this purpose, each of the 10 items received a dichotomous score of 1 if it was documented on the first day of patient care on the ward; otherwise, it was scored as 0. ResultsThe analysis consisted of 180 medical records. 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 (t178=–2.469; P=.01; d=–0.428). When looking at the significant changes of the 10 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=.02), and pain (P=.008) was less complete in the EMR. The completeness remained unchanged for the documentation of pulse (P=.28), blood pressure (P=.47), body temperature (P=.497), and reanimation status (P=.73). ConclusionsImplementing EMRs can influence the completeness of documentation, with a possible change in both increased and 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 decrease or increase the staff’s 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. Trial RegistrationGerman Clinical Trials Register DRKS00023343; https://drks.de/search/de/trial/DRKS00023343https://medinform.jmir.org/2024/1/e47761 |
| spellingShingle | Florian Wurster Marina Beckmann Natalia Cecon-Stabel Kerstin Dittmer Till Jes Hansen Julia Jaschke Juliane Köberlein-Neu Mi-Ran Okumu Carsten Rusniok Holger Pfaff Ute Karbach The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis JMIR Medical Informatics |
| title | The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis |
| title_full | The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis |
| title_fullStr | The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis |
| title_full_unstemmed | The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis |
| title_short | The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis |
| title_sort | implementation of an electronic medical record in a german hospital and the change in completeness of documentation longitudinal document analysis |
| url | https://medinform.jmir.org/2024/1/e47761 |
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