Concordance of information in parallel electronic and paper based patient records

Abstract

Objective: to evaluate the results of parallel use of both paper based and electronic patient records with respect to concordance of corresponding information in two continuously updated versions of the same records. Design: retrospective evaluation of patient records, comparing documentation in electronic and paper based patient records. Setting: Department of Neurology in a Norwegian university hospital using paper based and electronic patient records in parallel during migration towards completely electronic patient records. Material: electronic and paper based patient records of 90 randomly selected patients visiting the department between 1 November 1997 and 30 April 1999. Results: seven percent of the electronic documents were significantly different in some way from the corresponding paper documents. About 4–13% of the documents in the electronic record were missing; one percent were missing from the paper record. Conclusion: parallel use of electronic and paper based patient records has resulted in inconsistencies between the record systems in our setting. Documentation is missing in both the electronic and paperbased records. When implementing electronic record systems intended to operate in parallel with paperbased systems, focus should be on securing the validity of all versions of the record.

Introduction

The implementation of electronic patient record (EPR) systems in hospitals is a major task [1], [2], [3]. The diversity and size of the hospital organization together with the complexity of the information systems make widespread implementation of EPR systems an overwhelming effort for most hospitals of more than minimal size [4], [5], [6]. To avoid dramatic organizational changes and to secure operational records all the time during the implementation process, gradual replacement of paper-based records by electronic systems may be a rational strategy [7], [8], [9], [10]. In this way, electronic handling of various aspects of the patient record can be implemented gradually over time, leaving room for the organization to get accustomed to new ways of working while paper records are still available as backup.

This strategy does, however, imply parallel maintenance of both paper records and electronic records until the EPR system has completely substituted the paper based patient records. Information systems operating in parallel, i.e. handling corresponding and continuously updated information, are at risk of becoming inconsistent. This definitely is the situation when patient records are maintained in both electronic and paper based versions, in which updating of one system is possible without necessarily updating the other. If functionality of the electronic system and overall routines for production of patient records are not focused on keeping both systems consistent, chances are substantial that inconsistencies of the information in the two systems will arise. Information present in one system may be missing or appear different in the other, leaving doubt regarding the reliability of information in the two systems. The aspect of inconsistency is a qualitative aspect that must be considered when clinical patient documentation is maintained in several different information systems. Needless to say, failure of the record systems to provide consistent information may have serious consequences. In addition to consequences for the delivery of care and legal problems, failure of the record systems to provide correct and complete documentation of patients encounters with the health care organization may cause decreased confidence in the validity of the patient record among users of the record and among patients. Users may end up feeling obliged to check several sources for verification of important information, causing frustration and impaired efficiency.

On this background we wanted to evaluate the consistency of information in electronic patient records and corresponding paper records in a setting where paper records operate in parallel with an electronic patient record system. Specifically, we wanted to measure the degree of concordance between defined parts of the paper based and electronic records with regard to informational content. Our hypothesis was that there are inconsistencies between the systems, caused by failure to update both parallel versions of the record. Additionally, we expected paper records in general to contain more complete information than electronic records, due to routines for maintaining patient records in our department at the time.