Which record-keeping system is more accurate for documenting a patient's progress, paper or electronic?
There were mixed results after researchers reviewed 500 progress notes written by physicians at Beaumont Hospital in Royal Oak, Mich., as it transitioned to an electronic health record system.
“Inaccurate documentation was significantly higher in the EHR” by a rate of more than 5 to 1 (24.4% error rate with the EHR, 4.4% with paper), according to a study published in the Journal of the American Medical Association.
But in terms of expected physical examination findings, omissions were far more likely with paper notes compared with EHR notes (41.2% vs. 17.6%).
The study also found that error rates for resident physicians were a third lower than for attending physicians, (5.3% to 17.3%).
For the early part of the study period, the hospital was using an EHR from Epic Systems, but physicians were still using paper to initially document patient progress notes on paper charts, according to the study's lead author, Dr. Siddhartha Yadav, an attending physician in the internal medicine department at the hospital in suburban Detroit.
Those paper-based physician notes were then transcribed and placed into the electronic record. From July 1, 2012, forward, physicians documented directly to the patients' record in the EHR.
Researchers primarily looked for accuracy, inaccuracy and omission of information in the sample records, with secondary endpoints including the time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training.
Nationwide in the physician informatics community, there is an ongoing discussion about how to best use the cut-and-paste functions built into EHRs. These tools enable a physician to update a record by populating a current record with data already in the EHR from previous encounters.
On the one hand, the functions aim to save physicians time. On the other, they can introduce errors and have even been attacked as a vehicle for committing billing fraud.
Some of the inaccuracies found in the Beaumont study resulted from copying and pasting of past notes into the record, repeating information that was no longer accurate for the patient's changed status, Yadav said.
Other errors may have stemmed from failings of memory.
“The EHR allows you to copy and paste and there are default settings,” Yadav said. It also can bring up a template for an exam that's been already filled in by the physician and he or she is responsible for deleting items not—or no longer—relevant.
“In paper charts, you rounded and you went in and the chart was next to the patient and you documented at that time,” Yadev said. “With the electronic chart, you can go home and document later. How much do you remember? That's part of the problem.”
Yadev suggested two possible reasons the notes of residents scored higher than those of attendings – residents are under far more scrutiny and since they're younger, are often more computer savvy than their older overseers.
Yadev said he plans to do a follow up study to measure progress.
“Our study looks at the initial implementation,” he said. “Since then, we have been much more cautious about when we should copy and paste and make sure what we've pasted is accurate for that. There has been a lot of discussion about when is copy and pastes appropriate.”
“I don't think EHRs are going away,” he said. “It's not a problem with EHRs; it's how we use EHRs. We will improve.”