Reliability study of clinical electronic records with paper records in the NSW Public Oral Health Service

摘要

Aim: Electronic health record (EHR) data have great potential for reuse in research and patient care quality improvement initiatives. However, in dual systems, where both electronic and paper health records are used, inconsistencies and errors may occur. The objective of this study was to determine the degree of agreement between EHR clinical data and paper records for reuse in clinical oral health research and quality improvement initiatives.Methods: A random sample of 200 EHRs for adolescents from eight Area Health Services was obtained from the Information System for Oral Health New South Wales database of 29?599 records, and compared with 200?paper records for adolescents that were stored at clinics. The records were analysed for data reliability. The electronic records were percentage weighted to reflect the number of adolescents treated in each of the Area Health Services.Results: The results showed an overall 95.0% agreement between the 200?individual EHRs and the 200?clinic-stored paper records. In 1.5% of cases, information contained in the paper record was not uploaded into the EHR, and in 3.5% of cases, information contained in the EHR was missing from the paper record.Conclusions: It is possible to conclude that more deficiencies occurred in paper records compared with EHRs. These deficiencies should be taken into account if EHRs are to be reused for clinical oral health research or quality improvement initiatives. Considering the missing data and the great strides in information system technology, it would be logical to adopt one system, with a focus on electronic records to replace the paper records.