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Wurster F, Fütterer G, Beckmann M, Dittmer K, Jaschke J, Köberlein-Neu J, Okumu MR, Rusniok C, Pfaff H, Karbach U. The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals-A Systematic Review. J Med Syst 2022; 46:54. [PMID: 35781136 PMCID: PMC9252957 DOI: 10.1007/s10916-022-01840-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
The major impact on healthcare through the ongoing digital transformation and new technologies results in opportunities for improving quality of care. Electronic patient records (EPR) are a substantial part in this transformation, even though their influence on documentation remains often unclear. This review aims to answer the question of which effect the introduction of the EPR has on the documentation proper in hospitals. To do this, studies are reviewed that analyze the documentation itself, rather than merely conducting interviews or surveys about it. Several databases were searched in this systematic review (PubMed including PubMed, PubMed Central and Medline; PDQ Evidence; Web of Science Core Collection; CINHAL). To be included, studies needed to analyze written documentation and empirical data, be in either German or English language, published between 2010 and 2020, conducted in a hospital setting, focused on transition from paper-based to electronic patient records, and peer reviewed. Quantitative, qualitative and mixed methods studies were included. Studies were independently screened for inclusion by two researchers in three stages (title, abstract, full text) and, in case of disagreement, discussed with a third person from the research team until consensus was reached. The main outcome assessed was whether the studies indicated a negative or positive effect on documentation (e.g. changing the completeness of documentation) by introducing an EPR. Mixed Methods Appraisal Tool was used to assess the individual risk of bias in the included studies. Overall, 264 studies were found. Of these, 17 met the inclusion criteria and were included in this review. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation such as an improved completeness or guideline adherence of the documentation. Six of 17 showed a mixed effect with positive and negative or no changes. No study showed an exclusively negative effect. Most studies found a positive effect of EPR introduction on documentation. However, it is difficult to draw specific conclusions about how the EPR affects or does not affect documentation since the included studies examined a variety of outcomes. As a result, various scenarios are conceivable with higher or reduced burden for practitioners. Additionally, the impact on treatment remains unclear.
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Affiliation(s)
- Florian Wurster
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany.
| | - Garret Fütterer
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Marina Beckmann
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Kerstin Dittmer
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Julia Jaschke
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Mi-Ran Okumu
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Carsten Rusniok
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Ute Karbach
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
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Kasahara S, Yoshizaki K, Yamashita T, Takeda H. Evaluating the benefit of introducing medical clerks as transcriptionists to assist physicians in outpatient clinics: a quantitative analysis of medical records by counting characters. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:4637-4641. [PMID: 24110768 DOI: 10.1109/embc.2013.6610581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This study evaluates the effects of the medical clerks introduced to reduce physicians' workloads in outpatient clinics by assisting with their documentation processes (e.g., the production of electronic medical records (EMRs)). The volume of information written in narrative text in EMRs from 2007 (pre-introduction of medical clerks) to 2012 (post-introduction) was measured by counting Japanese characters. The total number of medical records for analysis was 1,577. The average number of characters in EMRs increased from before the introduction of medical clerks to afterwards regardless of the types of documents (subjective or objective data) or visits (first or second visits). We conclude that introducing medical clerks improves the quantity of outpatients' medical records and that such a character-counting method is useful for evaluating the benefit of the introduction of medical clerks to assist physicians.
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