背景:电子病历(EMR)被认为是医疗保健系统数字化转型的关键组成部分。EMR的实施承诺各种改进,例如,在信息的可用性方面,协调护理,或患者安全,并且是大数据分析所必需的。为了确保这些可能性,包含的文档必须是高质量的。在这件事上,数据质量最常描述的维度是文档的完整性。在这方面,很少有人知道如何以及为什么文档的完整性可能会在实施EMR后发生变化。
目的:本研究旨在比较纸质病历和EMR中文档的完整性,并讨论EMR对文档完整性的可能影响。
方法:进行回顾性文献分析,比较纸质病历和EMR的完整性。数据是在德国学术教学医院的骨科病房实施EMR之前和之后收集的。匿名记录代表3周期间的所有治疗患者。不成对,双尾t检验,卡方检验,和相对风险进行了计算,以分析和比较2种记录类型的平均完整性和10个具体项目的平均完整性(血压,体温,诊断,饮食,排泄物,高度,疼痛,脉搏,重新动画状态,和重量)。为此,如果在病房接受患者护理的第一天记录,则10个项目中的每个项目均获得1分的二分;否则,得分为0。
结果:分析包括180份医疗记录。纸质病历的平均完整性为6.25(SD2.15),分为10,EMR显着上升到平均7.13(SD2.01)(t178=-2.469;P=0.01;d=-0.428)。当详细查看这10个项目的重大变化时,饮食记录(P<.001),高度(P<.001),EMR中的体重(P<.001)更完整,而诊断文件(P<.001),排泄物(P=0.02),在EMR中疼痛(P=0.008)较不完全。脉冲记录的完整性保持不变(P=.28),血压(P=0.47),体温(P=0.497),和恢复状态(P=.73)。
结论:实施EMR会影响文档的完整性,完整性的增加和减少都可能发生变化。然而,决定这些变化的机制往往被忽视。有一些机制可以促进提高文件的完整性,并可以减少或增加由文件工作造成的工作人员负担。需要进行研究,以利用这些机制,并为所有利益相关者的利益而相互获利。
背景:德国临床试验注册DRKS00023343;https://drks。de/search/de/trial/DRKS00023343.
BACKGROUND: Electronic 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.
OBJECTIVE: This 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.
METHODS: A 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.
RESULTS: The 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).
CONCLUSIONS: Implementing 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.
BACKGROUND: German Clinical Trials Register DRKS00023343; https://drks.de/search/de/trial/DRKS00023343.