Bibliographic Details
| Title: |
The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis |
| Authors: |
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 |
| Source: |
JMIR Medical Informatics, Vol 12, p e47761 (2024) |
| Publisher Information: |
JMIR Publications, 2024. |
| Publication Year: |
2024 |
| Collection: |
LCC:Computer applications to medicine. Medical informatics |
| Subject Terms: |
Computer applications to medicine. Medical informatics, R858-859.7 |
| More Details: |
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 |
| Document Type: |
article |
| File Description: |
electronic resource |
| Language: |
English |
| ISSN: |
2291-9694 |
| Relation: |
https://medinform.jmir.org/2024/1/e47761; https://doaj.org/toc/2291-9694 |
| DOI: |
10.2196/47761 |
| Access URL: |
https://doaj.org/article/7939378971ff4d349566be59ad905bc9 |
| Accession Number: |
edsdoj.7939378971ff4d349566be59ad905bc9 |
| Database: |
Directory of Open Access Journals |
