Comparing Paper-based with Electronic Patient Records: Lessons Learned during a Study on Diagnosis and Procedure Codes

摘要

Paper-based and electronic patient records generally are used in parallel to support different tasks. Many studies comparing their quality do not report sufficiently on the methods used. Few studies refer to the patient. Instead, most regard the paper record as the gold standard. Focusing on quality criteria, the current study compared the two records patient by patient, presuming that each might hold unique advantages. For surgical patients at a nonuniversity hospital, diagnosis and procedure codes from the hospital's electronic patient record (EPR set) were compared with the paper records (PPR set). Diagnosis coding from the paper-based patient record resulted in minor qualitative advantages. The EPR documentation showed potential advantages in both quality and quantity of procedure coding. As in many previous studies, the current study relied on a single individual to extract and transform contents from the paper record to compare PPR with EPR. The exploratory study, although limited, supports previous views of the complementary nature of paper and electronic records. The lessons learned from this study are that medical professionals should be cognizant of the possible discrepancies between paper and electronic information and look toward combining information from both records whenever appropriate. The inadequate methodology (transformations done by a single individual) used in the authors' study is typical of other studies in the field. The limited generalizability and restricted reproducibility of this commonly used approach emphasize the need to improve methods for comparing paper-based with electronic versions of a patient's chart.