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Despite widespread adoption and maturity, paper persistence endures in many Electronic Health Record (EHR) systems, particularly for complex workflows involving multiple steps from different stakeholders separated in time. In our health system, Latent Tuberculosis Infection (LTBI) testing was one such workflow where a Tuberculin Skin Test (TST) must be administered and then correctly read 48-72 hours later and documented. This paper discusses a low-resource workflow analysis and clinical decision support approach to replace a paper workflow and garner the benefits of the EHR for clearer documentation and retrieval of LTBI results. Our approach resulted in a significant increase in completed TST documentation, 57% (24/42) to 95% (18/19), P < 0.003. Human-centered design practices such as work system analysis and formative usability testing are feasible with limited resources and improve the likelihood of success of electronic workflows by designing solutions that fit existing clinical workflows and automating processes wherever possible.

Background: Health care providers worldwide are rapidly adopting electronic medical record (EMR) systems, replacing paper record-keeping systems. Despite numerous benefits to EMRs, the environmental emissions associated with medical record-keeping are unknown. Given the need for urgent climate action, understanding the carbon footprint of EMRs will assist in decarbonizing their adoption and use., Objective: We aimed to estimate and compare the environmental emissions associated with paper medical record-keeping and its replacement EMR system at a high-volume eye care facility in southern India., Methods: We conducted the life cycle assessment methodology per the ISO (International Organization for Standardization) 14040 standard, with primary data supplied by the eye care facility. Data on the paper record-keeping system include the production, use, and disposal of paper and writing utensils in 2016. The EMR system was adopted at this location in 2018. Data on the EMR system include the allocated production and disposal of capital equipment (such as computers and routers); the production, use, and disposal of consumable goods like paper and writing utensils; and the electricity required to run the EMR system. We excluded built infrastructure and cooling loads (eg. buildings and ventilation) from both systems. We used sensitivity analyses to model the effects of practice variation and data uncertainty and Monte Carlo assessments to statistically compare the 2 systems, with and without renewable electricity sources., Results: This location's EMR system was found to emit substantially more greenhouse gases (GHGs) than their paper medical record system (195,000 kg carbon dioxide equivalents [CO 2 e] per year or 0.361 kg CO 2 e per patient visit compared with 20,800 kg CO 2 e per year or 0.037 kg CO 2 e per patient). However, sensitivity analyses show that the effect of electricity sources is a major factor in determining which record-keeping system emits fewer GHGs. If the study hospital sourced all electricity from renewable sources such as solar or wind power rather than the Indian electric grid, their EMR emissions would drop to 24,900 kg CO 2 e (0.046 kg CO 2 e per patient), a level comparable to the paper record-keeping system. Energy-efficient EMR equipment (such as computers and monitors) is the next largest factor impacting emissions, followed by equipment life spans. Multimedia Appendix 1 includes other emissions impact categories., Conclusions: The climate-changing emissions associated with an EMR system are heavily dependent on the sources of electricity. With a decarbonized electricity source, the EMR system's GHG emissions are on par with paper medical record-keeping, and decarbonized grids would likely have a much broader benefit to society. Though we found that the EMR system produced more emissions than a paper record-keeping system, this study does not account for potential expanded environmental gains from EMRs, including expanding access to care while reducing patient travel and operational efficiencies that can reduce unnecessary or redundant care., (©Cordelia Kwon, Lernik Essayei, Michael Spencer, Tom Etheridge, Rengaraj Venkatesh, Natrajan Vengadesan, Cassandra L Thiel. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.02.2024.)

Background: There are limited data on the accuracy of documentation of trauma activations in the electronic medical record (EMR) compared with a paper chart. Our primary objective was to compare the accuracy of documentation between a paper chart and EMR in pediatric trauma., Methods: We studied video recordings of trauma activations at a level 1 pediatric trauma center. These videos were reviewed, and data points collected were used to compare accuracy of documentation in the paper chart and EMR., Results: We reviewed 106 videos with 1614 data points collected. Of those, 805 data points were compared with their corresponding paper chart with 710 data points correctly documented (88.2%). The remaining 809 data points were compared with their corresponding electronic documentation after implementation of the EMR with 681 data points being correctly documented (84.2%). Overall, we found that paper documentation was significantly more accurate than the EMR (p = 0.019). When analyzed in subcategories of pre-arrival information, primary and secondary survey, and interventions, paper documentation was found to be significantly more accurate than the EMR for components of the primary and secondary survey (87.3% vs. 80.4%, p = 0.001). There was no significant difference in accuracy of documentation between paper and EMR for pre-arrival information (88.1% vs. 89.4%) or interventions (90.3% vs. 92%)., Conclusion: Documentation of trauma activations is overall more accurate using a paper chart than EMR. Although documentation was accurate for most categories using both a paper chart and EMR, we found significantly less accuracy in documentation of the primary and secondary survey in the EMR., Competing Interests: Declaration of Competing Interest The authors have no disclosures or conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Paper patient file sharing has clearly been identified as a risk behavior for the COVID-19 virus transmission in radiotherapy units. In order to overcome this, the ONCORAD radiotherapy units worked on total dematerialization of the paper patient file, within 3 weeks. The methodology is based on a quality approch. This work has led to a convincing improvement in the management of risks a priori and a smoother patient care workflow., (Copyright © 2021 Société française de radiothérapie oncologique (SFRO). Published by Elsevier Masson SAS. All rights reserved.)

Purpose: To evaluate the effect of electronic and paper-based standardized nursing care plans (SNCPs) use on quality of nurses' documentation., Methods: Using quasi-experimental design, two wards were grouped into electronic and paper-based wards. Nurses were trained to use electronic- and paper-based SNCPs for care-planning and documentation. Data was collected before, 3, and 6 months postintervention and analyzed with SPSS version 20., Findings: There was improvement in documentation quality in the two wards after introducing SNCPs with higher quality scores in the electronic ward postintervention., Conclusion: Providing SNCPs in electronic and paper formats is critical to improving nursing documentation., Implication for Nursing Practice: Adequate training and support for nurses are needed for successful implementation of SNCPs in electronic health records (EHRs) in developing nations., (© 2018 NANDA International, Inc.)

Electronic data capture is fast becoming the preferred method of collecting patient-reported outcome (PRO) data in clinical trials. Data collection can be site-based (clinical study site), and typically collected on a tablet, or field-based (subject's typical environment such as home, school, or workplace), and most often accomplished with handheld devices, such as a smartphone. While site and study subject compliance with protocol-specific data collection procedures using these devices is critical to trial success, so is the robustness of the device hardware and the software these devices use to capture the trial data. Technology failures and/or site or subject resistance to the electronic data capture protocol may lead a subject to record data on paper, which can result in undesirable data challenges. As such, both site and subject compliance issues and technology-related factors must be anticipated to adhere to the ePRO data collection plan. The objective of this paper is to provide the technology industry's best practice recommendations for optimizing ePRO data collection in clinical trials by proposing the inclusion of a planned approach to data collection that includes viable electronic backup strategies so that defaulting to a paper-based backup becomes unnecessary.

Background: The implementation of an electronic health record (EHR) with structured and standardized recording of patient data can improve data quality and reusability. Whether and how users perceive these advantages may depend on the preimplementation situation., Objective: To determine whether the influence of implementing a structured and standardized EHR on perceived EHR use, data quality, and data reuse differed for users working with paper-based records versus a legacy EHR before implementation., Methods: We used an electronic questionnaire to measure users' perception before implementation (2014), expected change, and perceived change after implementation (2016) on three themes. We included all health care professionals in two university hospitals in the Netherlands. Before jointly implementing the same structured and standardized EHR, one hospital used paper-based records and the other a legacy EHR. We compared perceptions before and after implementation for both centers. Additionally, we compared expected benefit with perceived benefit., Results: We received 7,611 responses (4,537 before and 3,074 after implementation) of which 5,707 (75%) were from professionals reading and recording patient data. A total of 975 (13%) professionals responded to both before and after implementation questionnaires. In the formerly paper-based center staff perceived improvement in all themes after implementation. The legacy EHR center experienced deterioration of perceived EHR use and data reuse, and only one improvement in EHR use. In both centers, for half of the aspects at least 45% of responders experienced results worse than expected preimplementation., Conclusion: Our results indicate that the preimplementation recording practice impacts the perceived effect of the implementation of a structured and standardized EHR. For almost half of the respondents the new EHR did not meet their expectations. Especially legacy EHR centers need to investigate the expectations as these might be different and less clear cut than those in paper-based centers. These expectations need to be addressed appropriately to achieve a successful implementation., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: To synthesize the findings of cognitive interview and usability studies performed to assess the measurement equivalence of patient-reported outcome (PRO) instruments migrated from paper to electronic formats (ePRO), and make recommendations regarding future migration validation requirements and ePRO design best practice., Methods: We synthesized findings from all cognitive interview and usability studies performed by a contract research organization between 2012 and 2015: 53 studies comprising 68 unique instruments and 101 instrument evaluations. We summarized study findings to make recommendations for best practice and future validation requirements., Results: Five studies (9%) identified minor findings during cognitive interview that may possibly affect instrument measurement properties. All findings could be addressed by application of ePRO best practice, such as eliminating scrolling, ensuring appropriate font size, ensuring suitable thickness of visual analogue scale lines, and providing suitable instructions. Similarly, regarding solution usability, 49 of the 53 studies (92%) recommended no changes in display clarity, navigation, operation, and completion without help. Reported usability findings could be eliminated by following good product design such as the size, location, and responsiveness of navigation buttons., Conclusions: With the benefit of accumulating evidence, it is possible to relax the need to routinely conduct cognitive interview and usability studies when implementing minor changes during instrument migration. Application of design best practice and selecting vendor solutions with good user interface and user experience properties that have been assessed in a representative group may enable many instrument migrations to be accepted without formal validation studies by instead conducting a structured expert screen review., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Background: Recent evidence suggests that screening with low dose computed tomography (LDCT) scans significantly reduces mortality from lung cancer. However, optimal methods to identify potentially eligible patients in primary care are not known. Using brief electronic screening forms administered prior to a primary care visit is a strategy to identify high risk, asymptomatic patients eligible for LDCT screening. The objective of this study was to compare the acceptability and feasibility of using brief electronic versus paper screening forms to identify eligible patients at high risk of developing lung cancer in primary care., Methods: A mixed method pilot comparative study was conducted in primary care. Practices were allocated to an electronic form (e-form) group or a paper-based form (p-form) group. Allocation was randomly assigned for the first practice then by alternation. Patients in the e-form practices completed forms at home via the web or in the waiting room on a tablet. Patients in p-form practices completed forms in waiting rooms. Interviews were conducted with patients, administrators, and primary care physicians (PCPs) about their experiences., Results: Six of 30 (20%) eligible practices agreed to participate. Over the 16-week study period, a total of 831 of an expected 1442 patients (58%) aged 55-74 years were enrolled; 573/690 (83%) patients in the e-form group and 258/752 (34%) in the p-form group. Of the 573 participants in the e-form group, 335 (58%) completed forms via the web; 238 (29%) did so via tablet. Twenty-four interviews were conducted with 15 patients, 5 administrative staff and 4 PCPs. Patients were willing to discuss lung cancer screening eligibility with their PCP. Staff members expressed low administrative burden except for an extra step to link appointment information to patient demographics to identify eligible patients. PCPs indicated that forms were reminders to discuss smoking cessation. PCPs in the e-form group reported that patients asked questions about screening., Conclusion: There was fairly low uptake by primary care practices. For e-forms to be feasible in practice workflow, electronic medical record software needs to link appointment information with patient eligibility requirements. The use of brief pre-consultation electronic screening forms for LDCT eligibility encouraged PCPs to discuss smoking cessation with patients.

This study examines a paper hand-held record and a shared electronic health record in an Australian tertiary hospital healthcare maternity setting and the role that both types of records play in facilitating integrated care among healthcare providers. A qualitative research design was used where five focus groups were conducted in two phases with 69 hospital healthcare providers. In total, 32 interviews were also carried out with general practitioners. Transcripts were analysed using qualitative content analysis. Three key themes were identified: (1) selective use of records; (2) records as communication of care; and (3) negativity about the use of records. This study demonstrates that healthcare providers do not effectively share information using either a paper hand-held record or a shared electronic health record. Considering a national commitment to e-health innovation, a multi-professional input, organisational support and continuing education are identified as crucial to realising the potential of a maternity shared electronic health record to facilitate integrated care.

Background: A robust medical claims review system is crucial for addressing fraud and abuse and ensuring financial viability of health insurance organisations. This paper assesses claims adjustment rate of the paper- and electronic-based claims reviews of the National Health Insurance Scheme (NHIS) in Ghana., Methods: The study was a cross-sectional comparative assessment of paper- and electronic-based claims reviews of the NHIS. Medical claims of subscribers for the year, 2014 were requested from the claims directorate and analysed. Proportions of claims adjusted by the paper- and electronic-based claims reviews were determined for each type of healthcare facility. Bivariate analyses were also conducted to test for differences in claims adjustments between healthcare facility types, and between the two claims reviews., Results: The electronic-based review made overall adjustment of 17.0% from GHS10.09 million (USD2.64 m) claims cost whilst the paper-based review adjusted 4.9% from a total of GHS57.50 million (USD15.09 m) claims cost received, and the difference was significant (p < 0.001). However, there were no significant differences in claims cost adjustment rate between healthcare facility types by the electronic-based (p = 0.0656) and by the paper-based reviews (p = 0.6484)., Conclusions: The electronic-based review adjusted significantly higher claims cost than the paper-based claims review. Scaling up the electronic-based review to cover claims from all accredited care providers could reduce spurious claims cost to the scheme and ensure long term financial sustainability.

The paper electrocardiogram (ECG) has been widely used for cardiac assessment for well over a century. ECGs can be obtained quickly and cheaply. For this reason, an ever-growing amount of paper ECG records continue to accumulate, some of which are stored into a paper-only format. Converting paper ECGs into digital form has been proposed as the most efficient means to store and analyze an otherwise cumbersome paper archive. In this article, a literature review was conducted for conversion algorithms, criticisms of said algorithms, applications, and standardization efforts. The algorithms were compared in tabulated form. Key functions that have advanced the conversion algorithms as well as remaining challenges are discussed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Data entry at the point of collection using mobile electronic devices may make data-handling processes more efficient and cost-effective, but there is little literature to document and quantify gains, especially for longitudinal surveillance systems., Objective: To examine the potential of mobile electronic devices compared with paper-based tools in health data collection., Methods: Using data from 961 households from the Rufiji Household and Demographic Survey in Tanzania, the quality and costs of data collected on paper forms and electronic devices were compared. We also documented, using qualitative approaches, field workers, whom we called 'enumerators', and households' members on the use of both methods. Existing administrative records were combined with logistics expenditure measured directly from comparison households to approximate annual costs per 1,000 households surveyed., Results: Errors were detected in 17% (166) of households for the paper records and 2% (15) for the electronic records (p < 0.001). There were differences in the types of errors (p = 0.03). Of the errors occurring, a higher proportion were due to accuracy in paper surveys (79%, 95% CI: 72%, 86%) compared with electronic surveys (58%, 95% CI: 29%, 87%). Errors in electronic surveys were more likely to be related to completeness (32%, 95% CI 12%, 56%) than in paper surveys (11%, 95% CI: 7%, 17%).The median duration of the interviews ('enumeration'), per household was 9.4 minutes (90% central range 6.4, 12.2) for paper and 8.3 (6.1, 12.0) for electronic surveys (p = 0.001). Surveys using electronic tools, compared with paper-based tools, were less costly by 28% for recurrent and 19% for total costs. Although there were technical problems with electronic devices, there was good acceptance of both methods by enumerators and members of the community., Conclusions: Our findings support the use of mobile electronic devices for large-scale longitudinal surveys in resource-limited settings.

Objective: There are concerns that structured electronic documentation systems can limit expressivity and encourage long and unreadable notes. We assessed the impact of an electronic clinical documentation system on the quality of admission notes for patients admitted to a general medical unit., Methods: This was a prospective randomized crossover study comparing handwritten paper notes to electronic notes on different patients by the same author, generated using a semistructured electronic admission documentation system over a 2-month period in 2014. The setting was a 4-team, 80-bed general internal medicine clinical teaching unit at a large urban academic hospital. The quality of clinical documentation was assessed using the QNOTE instrument (best possible score = 100), and word counts were assessed for free-text sections of notes., Results: Twenty-one electronic-paper note pairs (42 notes) written by 21 authors were randomly drawn from a pool of 303 eligible notes. Overall note quality was significantly higher in electronic vs paper notes (mean 90 vs 69, P < .0001). The quality of free-text subsections (History of Present Illness and Impression and Plan) was significantly higher in the electronic vs paper notes (mean 93 vs 78, P < .0001; and 89 vs 77, P = .001, respectively). The History of Present Illness subsection was significantly longer in electronic vs paper notes (mean 172.4 vs 92.4 words, P = .0001)., Conclusions: An electronic admission documentation system improved both the quality of free-text content and the overall quality of admission notes. Authors wrote more in the free-text sections of electronic documents as compared to paper versions., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Introduction: There have been several concerns about the quality of documentation in electronic health records (EHRs) when compared to paper charts. This study compares the accuracy of physical examination findings documentation between the two in initial progress notes., Methodology: Initial progress notes from patients with 5 specific diagnoses with invariable physical findings admitted to Beaumont Hospital, Royal Oak, between August 2011 and July 2013 were randomly selected for this study. A total of 500 progress notes were retrospectively reviewed. The paper chart arm consisted of progress notes completed prior to the transition to an EHR on July 1, 2012. The remaining charts were placed in the EHR arm. The primary endpoints were accuracy, inaccuracy, and omission of information. Secondary endpoints were time of initiation of progress note, word count, number of systems documented, and accuracy based on level of training., Results: The rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts (24.4% vs 4.4%). However, expected physical examination findings were more likely to be omitted in the paper notes compared to EHRs (41.2% vs 17.6%). Resident physicians had a smaller number of inaccuracies (5.3% vs 17.3%) and omissions (16.8% vs 33.9%) compared to attending physicians., Conclusions: During the initial phase of implementation of an EHR, inaccuracies were more common in progress notes in the EHR compared to the paper charts. Residents had a lower rate of inaccuracies and omissions compared to attending physicians. Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation., (© The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Electronic formats of patient-reported outcome (PRO) measures are now routinely used in clinical research studies. When changing from a validated paper and pen to electronic administration it is necessary to establish their equivalence. This study reports on the value of Rasch analysis in this process., Methods: Three groups of US pulmonary hypertension (PH) patients participated. The first completed an electronic version of the CAMPHOR Activity Limitation scale (e-sample) and this was compared with two pen and paper administrated samples (pp1 and pp2). The three databases were combined and analysed for fit to the Rasch model. Equivalence was evaluated by differential item functioning (DIF) analyses., Results: The three datasets were matched randomly in terms of sample size (n = 147). Mean age (years) and percentage of male respondents were as follows: e-sample (51.7, 16.0 %); pp1 (50.0, 14.0 %); pp2 (55.5, 40.4 %). The combined dataset achieved fit to the Rasch model. Two items showed evidence of borderline DIF. Further analyses showed the inclusion of these items had little impact on Rasch estimates indicating the DIF identified was unimportant., Conclusions: Differences between the performance of the electronic and pen and paper administrations of the CAMPHOR Activity Limitation scale were minor. The results were successful in showing how the Rasch model can be used to determine the equivalence of alternative formats of PRO measures.

One of the most significant changes in modern healthcare delivery has been the evolution of the paper record to the electronic health record (EHR). In this paper we argue that the primary change has been a shift in the focus of documentation from monitoring individual patient progress to recording data pertinent to Institutional Priorities (IPs). The specific IPs to which we refer include: finance/reimbursement; risk management/legal considerations; quality improvement/safety initiatives; meeting regulatory and accreditation standards; and patient care delivery/evidence based practice. Following a brief history of the transition from the paper record to the EHR, the authors discuss unintended or contested consequences resulting from this change. These changes primarily reflect changes in the organization and amount of clinician work and clinician-patient relationships. The paper is not a research report but was informed by an institutional ethnography the aim of which was to understand how the EHR impacted clinicians and administrators in a large, urban hospital in the United States. The paper was also informed by other sources, including the philosophies of Jacques Ellul, Don Idhe, and Langdon Winner., (© 2015 John Wiley & Sons Ltd.)

Purposes: This study aimed to compare between electronic medication administration records and paper-based records in the nursing time spent on various activities in a medication round and the medication administration processes followed by nurses in an Australian residential aged care home. It also aimed to identify the benefits and unintended adverse consequences of using the electronic medication administration records., Methods: Time-motion observation, taking of field notes, informal conversation and document review were used to collect data in two units of a residential aged care home. Each unit had one nurse administer medication. Seven nurses were observed over 12 morning shifts. Unit 1 used electronic medication administration records and Unit 2 used paper-based records., Results: No significant difference between the two units was found in the nursing time spent on various activities in a medication round, including documentation, verbal communication, medication administration, infection control and transit. Comparison of the medication administration processes between the electronic and paper-based medication administration records identified a procedural problem which violated the organization's documentation requirement. This problem was documenting before providing medication to a resident when using the paper-based records. It was not observed with the electronic medication administration records. Benefits of introducing the electronic medication administration records included improving nurses' compliance with documentation requirements, freedom from the error of signing twice, reducing the possibility of forgetting to medicate a resident, facilitating nurses to record the time of medication administration to a resident and increasing documentation space. Unintended adverse consequences of introducing the electronic medication administration records included inadequate information about residents, late addition of a new resident's medication profile in the records and nurses' forgetting to medicate a resident due to power outage of the portable device., Conclusions: The electronic medication administration records may not change nursing time spent on various activities in a medication round or substantially alter the medication administration processes, but can generate both benefits and unintended adverse consequences. Future research may investigate whether and how the adverse consequences can be prevented., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Introduction: The nursing care plan plays an essential role in supporting care provision in Australian aged care. The implementation of electronic systems in aged care homes was anticipated to improve documentation quality. Standardized nursing terminologies, developed to improve communication and advance the nursing profession, are not required in aged care practice. The language used by nurses in the nursing care plan and the effect of the electronic system on documentation quality in residential aged care need to be investigated., Purpose: To describe documentation practice for the nursing care plan in Australian residential aged care homes and to compare the quantity and quality of documentation in paper-based and electronic nursing care plans., Methods: A nursing documentation audit was conducted in seven residential aged care homes in Australia. One hundred and eleven paper-based and 194 electronic nursing care plans, conveniently selected, were reviewed. The quantity of documentation in a care plan was determined by the number of phrases describing a resident problem and the number of goals and interventions. The quality of documentation was measured using 16 relevant questions in an instrument developed for the study., Results: There was a tendency to omit 'nursing problem' or 'nursing diagnosis' in the nursing process by changing these terms (used in the paper-based care plan) to 'observation' in the electronic version. The electronic nursing care plan documented more signs and symptoms of resident problems and evaluation of care than the paper-based format (48.30 vs. 47.34 out of 60, P<0.01), but had a lower total mean quality score. The electronic care plan contained fewer problem or diagnosis statements, contributing factors and resident outcomes than the paper-based system (P<0.01). Both types of nursing care plan were weak in documenting measurable and concrete resident outcomes., Conclusions: The overall quality of documentation content for the nursing process was no better in the electronic system than in the paper-based system. Omission of the nursing problem or diagnosis from the nursing process may reflect a range of factors behind the practice that need to be understood. Further work is also needed on qualitative aspects of the nurse care plan, nurses' attitudes towards standardized terminologies and the effect of different documentation practice on care quality and resident outcomes., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objective: Healthcare institutions worldwide are moving to electronic health records (EHRs). These transitions are particularly numerous in the US where healthcare systems are purchasing and implementing commercial EHRs to fulfill federal requirements. Despite the central role of EHRs to workflow, the cognitive impact of these transitions on the workforce has not been widely studied. This study assesses the changes in cognitive workload among pediatric nurses during data entry and retrieval tasks during transition from a hybrid electronic and paper information system to a commercial EHR., Materials and Methods: Baseline demographics and computer attitude and skills scores were obtained from 74 pediatric nurses in two wards. They also completed an established and validated instrument, the NASA-TLX, that is designed to measure cognitive workload; this instrument was used to evaluate cognitive workload of data entry and retrieval. The NASA-TLX was administered at baseline (pre-implementation), 1, 5 and 10 shifts and 4 months post-implementation of the new EHR., Results: Most nurse participants experienced significant increases of cognitive workload at 1 and 5 shifts after "go-live". These increases abated at differing rates predicted by participants' computer attitudes scores (p = 0.01)., Conclusions: There is substantially increased cognitive workload for nurses during the early phases (1-5 shifts) of EHR transitions. Health systems should anticipate variability across workers adapting to "meaningful use" EHRs. "One-size-fits-all" training strategies may not be suitable and longer periods of technical support may be necessary for some workers., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Although the electronic medical record reduces errors and improves patient safety, most emergency departments continue to use paper documentation for trauma resuscitations. The purpose of this study was to compare the completeness of paper documentation with that of electronic documentation for trauma resuscitations., Methods: The setting was a level I pediatric trauma center where 100% electronic documentation was achieved in August 2012. A random sample of trauma resuscitations documented by paper (n=200) was compared with a random sample of trauma resuscitations documented electronically (n=200) to identify the presence or absence of the documentation of 11 key data elements for each trauma resuscitation., Results: The electronic documentation more frequently captured 5 data elements: time of team activation (100% vs 85%, P<.00), primary assessment (94% vs 88%, P<.036), arrival time of attending physician (98% vs 93.5%, P<.026), intravenous fluid volume in the emergency department (94% vs 88%, P<.036), and disposition (100% vs 89.5%, P<.00). The paper documentation more often recorded one data element: volume of intravenous fluids administered prior to arrival (92.5% vs 100%, P<.00). No statistical difference in documentation rates was found for 5 data elements: vital signs, treatment by emergency medical personnel, arrival time in the emergency department, and level of trauma alert activation., Discussion: Electronic documentation produced superior records of pediatric trauma resuscitations compared with paper documentation. Because the electronic medical record improves patient safety, it should be adopted as the standard documentation method for all trauma resuscitations., (Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

Rationale, Aims and Objectives: Understanding the impact of health information technology on doctor-patient interaction is vital to designing better electronic health records (EHRs). This article quantitatively examines and compares clinically experienced physicians' interactions with patients using paper or EHRs in ambulatory primary care settings., Methods: Clinical encounters using paper or EHRs were recorded with high-resolution video cameras to capture physicians' interactions with the health records and patients. All videos were coded using quantified video coding methodology to understand how physicians interacted with EHRs and patients through measuring eye gaze durations. Statistical analysis was conducted to compare the results of the paper and EHR visits., Results: Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits, 40 with paper and 40 with EHRs were recorded. The proportion of time physicians spent gazing at medical records during EHR visits was significantly more than in paper chart visits (35.2 versus 22.1%, P = 0.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared with when using a paper chart (52.6 versus 45.6%, P = 0.041)., Conclusions: For this group of family medicine physicians, more time was spent looking at the EHR screen than paper records and a little less time looking at the patient. These findings may negatively affect the patient perception of the visit with the physician and have implications for the design of future EHRs., (© 2014 John Wiley & Sons, Ltd.)

Background: Electronic medical records are becoming an integral part of healthcare delivery., Objective: The goal of this study was to compare paper documentation versus electronic medical record for non-traumatic chest pain to determine differences in time for physicians to complete medical records using paper versus electronic mediums. We also assessed physician satisfaction with the electronic format., Methods: We conducted this before-after study in a single large tertiary care academic emergency department. In the 'Before Period', stopwatches determined the time for paper medical recording. In the 'After Period', a template-based electronic medical record was introduced and the time for electronic recording was measured. The time to record in the before and after periods were compared using a two-sided t test. We surveyed physicians to assess satisfaction., Results: We enrolled 100 non-traumatic patients with chest pain in the before period and 73 in the after period. The documentation time was longer using electronic charting, (9.6±5.9 min vs 6.1±2.5 min; p<0.001). 18 of 20 physicians participating in the after period completed surveys. Physicians were not satisfied with the electronic patient recording for non-traumatic chest pain., Conclusions: This is the first study that we are aware of which compared paper versus electronic medical records in the emergency department. Electronic recording took longer than paper records. Physicians were not satisfied using this electronic record. Given the time pressures on emergency physicians, a solution to minimise the charting time using electronic medical records must be found before widespread uptake of electronic charting will be possible., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

This study examined the effectiveness of an inpatient electronic medication record system in reducing medication errors in Singaporean hospitals. This pre- and post-intervention study involving a control group was undertaken in two Singaporean acute care hospitals. In one hospital the inpatient electronic medication record system was implemented while in another hospital the paper-based medication record system was used. The mean incidence difference in medication errors of 0.06 between pre-intervention (0.72 per 1000 patient days) and post-intervention (0.78 per 1000 patient days) for the two hospitals was not statistically significant (95%, CI: [0.26, 0.20]). The mean incidence differences in medication errors relating to prescription, dispensing, and administration were also not statistically different. Common system failures involved a lack of medication knowledge by health professionals and a lack of a systematic approach in identifying correct dosages. There was no difference in the incidence of medication errors following the introduction of the electronic medication record system. More work is needed on how this system can reduce medication error rates and improve medication safety., (© 2013 Wiley Publishing Asia Pty Ltd.)

Objective: To evaluate quantitative and qualitative differences in documentation of the ophthalmic examination between paper and electronic health record (EHR) systems., Design: Comparative case series., Participants: One hundred fifty consecutive pairs of matched paper and EHR notes, documented by 3 attending ophthalmologist providers., Methods: An academic ophthalmology department implemented an EHR system in 2006. Database queries were performed to identify cases in which the same problems were documented by the same provider on different dates, using paper versus EHR methods. This was done for 50 consecutive pairs of examinations in 3 different diseases: age-related macular degeneration (AMD), glaucoma, and pigmented choroidal lesions (PCLs). Quantitative measures were used to compare completeness of documenting the complete ophthalmologic examination, as well as disease-specific critical findings using paper versus an EHR system. Qualitative differences in paper versus EHR documentation were illustrated by selecting representative paired examples., Main Outcome Measures: (1) Documentation score, defined as the number of examination elements recorded for the slit-lamp examination, fundus examination, and complete ophthalmologic examination and for critical clinical findings for each disease. (2) Paired comparison of qualitative differences in paper versus EHR documentation., Results: For all 3 diseases (AMD, glaucoma, PCL), the number of complete examination findings recorded was significantly lower with paper than the EHR system (P ≤ 0.004). Among the 3 individual examination sections (general, slit lamp, fundus) for the 3 diseases, 5 of the 9 possible combinations had significantly lower mean documentation scores with paper than EHR notes. For 2 of the 3 diseases, the number of critical clinical findings recorded was significantly lower using paper versus EHR notes (P ≤ 0.022). All (150/150) paper notes relied on graphical representations using annotated hand-drawn sketches, whereas no (0/150) EHR notes contained drawings. Instead, the EHR systems documented clinical findings using textual descriptions and interpretations., Conclusions: There were quantitative and qualitative differences in the nature of paper versus EHR documentation of ophthalmic findings in this study. The EHR notes included more complete documentation of examination elements using structured textual descriptions and interpretations, whereas paper notes used graphical representations of findings., Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article., (Copyright © 2013 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment., Methods: This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated., Results: Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms)., Conclusions: Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Purpose: To compare accuracy and speed of keyboard and mouse electronic health record (EHR) documentation strategies with those of a paper documentation strategy., Design: Prospective cohort study., Methods: Three documentation strategies were developed: (1) keyboard EHR, (2) mouse EHR, and (3) paper. Ophthalmology trainees recruited for the study were presented with 5 clinical cases and documented findings using each strategy. For each case-strategy pair, findings and documentation time were recorded. Accuracy of each strategy was calculated based on sensitivity (fraction of findings in actual case that were documented by subject) and positive ratio (fraction of findings identified by subject that were present in the actual case)., Results: Twenty subjects were enrolled. A total of 258 findings were identified in the 5 cases, resulting in 300 case-strategy pairs and 77 400 possible total findings documented. Sensitivity was 89.1% for the keyboard EHR, 87.2% for mouse EHR, and 88.6% for the paper strategy (no statistically significant differences). The positive ratio was 99.4% for the keyboard EHR, 98.9% for mouse EHR, and 99.9% for the paper strategy (P < .001 for mouse EHR vs paper; no significant differences between other pairs). Mean ± standard deviation documentation speed was significantly slower for the keyboard (2.4 ± 1.1 seconds/finding) and mouse (2.2 ± 0.7 seconds/finding) EHR compared with the paper strategy (2.0 ± 0.8 seconds/finding). Documentation speed of the mouse EHR strategy worsened with repetition., Conclusions: No documentation strategy was perfectly accurate in this study. Documentation speed for both EHR strategies was slower than with paper. Further studies involving total physician time requirements for ophthalmic EHRs are required., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Healthcare professionals develop workarounds rather than using electronic health record (EHR) systems. Understanding the reasons for workarounds is important to facilitate user-centered design and alignment between work context and available health information technology tools., Objective: To examine both paper- and computer-based workarounds to the use of EHR systems in three benchmark institutions., Methods: Qualitative data were collected in 11 primary care outpatient clinics across three healthcare institutions. Data collection methods included direct observation and opportunistic questions. In total, 120 clinic staff and providers and 118 patients were observed. All data were analyzed using previously developed workaround categories and examined for potential new categories. Additionally, workarounds were coded as either paper- or computer-based., Results: Findings corresponded to 10 of 11 workaround categories identified in previous research. All 10 of these categories applied to paper-based workarounds; five categories also applied to computer-based workarounds. One new category, no correct path (eg, a desired option did not exist in the computer interface, precipitating a workaround), was identified for computer-based workarounds. The most consistent reasons for workarounds across the three institutions were efficiency, memory, and awareness., Conclusions: Consistent workarounds across institutions suggest common challenges in outpatient clinical settings and failures to accommodate these challenges in EHR design. An examination of workarounds provides insight into how providers adapt to limiting EHR systems. Part of the design process for computer interfaces should include user-centered methods particular to providers and healthcare settings to ensure uptake and usability.

Purpose: To describe the paper-based and electronic formats of resident admission forms used in several aged care facilities in Australia and to compare the extent to which resident admission information was documented in paper-based and the electronic health records., Methods: Retrospective auditing and comparison of the documentation quality of paper-based and electronic resident admission forms were conducted. A checklist of admission data was qualitatively derived from different formats of the admission forms collected. Three measures were used to assess the quality of documentation of the admission forms, including completeness rate, comprehensiveness rate and frequency of documented data element. The associations between the number of items and their completeness and comprehensiveness rates were estimated at a general level and at each information category level., Results: Various paper-based and electronic formats of admission forms were collected, reflecting varying practice among the participant facilities. The overall completeness and comprehensiveness rates of the admission forms were poor, but were higher in the electronic health records than in the paper-based records (60% versus 56% and 40% versus 29% respectively, p<0.01). There were differences in the overall completeness and comprehensiveness rates between the different formats of admission forms (p<0.01). At each information category level, varying degrees of difference in the completeness and comprehensiveness rates were found between different form formats and between the paper-based and the electronic records. A negative association between the completeness rate and the number of items in a form was found at each information category level (p<0.01), i.e., more data items designed in a form, the less likely that the items would be completely filled. However, the associations between the comprehensiveness rates and the number of items were highly positive at both overall and individual information category levels (p<0.01), suggesting more items designed in a form, more information would be captured., Conclusion: Better quality of documentation in resident admission forms was identified in the electronic documentation systems than in previous paper-based systems, but still needs to be further improved in practice. The quality of documentation of resident admission data should be further analysed in relation to its specific content., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: The Urticaria Patient Daily Diary (UPDD), originally developed on paper, is a measure of key symptoms of chronic idiopathic urticaria (CIU). The development of the electronic version (eUPDD) involved moderate modifications to the appearance of the paper version., Objective: This study assessed the measurement equivalence of the electronic and paper versions of the UPDD in a sample of patients with CIU., Methods: This was a cross-over study of patients with moderate-severe CIU refractory to H1 antihistamines. Patients were randomized to either the eUPDD followed by the paper UPDD or vice versa. The UPDD includes morning and evening questions; both sets were administered together in this study. An hour-long filler task was given between paper and electronic administrations. Patients with stable symptoms between the two assessments were included in the analyses. Cohen's kappa coefficients and intraclass correlation coefficients (ICC) were computed as applicable to assess equivalence., Results: A total of 91 patients participated (mean age 43 years, 79.1 % female). Symptoms were stable between assessments for 67-74 (74-81 %) patients (varied by symptom). Kappa coefficients ranged from 0.82 to 1.00 for the individual UPDD items. For the Urticaria Activity Score (the sum of the 'itch severity' and 'number of hives' item scores) the ICC was 0.90 for the morning (Wilcoxon p = 0.331) and 0.95 for the evening (Wilcoxon p = 0.836)., Conclusions: All test-retest statistics in this study were well above the accepted threshold, indicating excellent agreement between the two administration methods. Findings support the measurement equivalence of the electronic and paper versions of the UPDD to measure CIU symptoms.

While the digitization of medical data within electronic health records has been introduced in some areas, massive amounts of paper-based health records are still produced on a daily basis. This data has to be stored for decades due to legal reasons but is of no benefit for research organizations, as the unstructured medical data in paper-based health records cannot be efficiently used for clinical studies. This paper presents a system for the recognition and privacy preservation of personal data in paper-based health records with the aim to provide clinical studies with medical data gained from existing paper-based health records.

The introduction of an electronic medical record (EMR) has been rapidly accelerating in South Korea. The EMR was expected to improve quality of care, readability, availability, and the quality of data. However, the reluctance of healthcare providers to use the EMR may have caused a reduction of information recorded in EMRs. The purpose of this study was to identify whether there was any loss of information following the introduction of a narrative text-based EMR in the recording of chief complaint and present illness in inpatient medical records. Inpatient medical records of a university hospital were retrospectively evaluated for one month before and one month after the introduction of the EMR in June 2006. The volume of information for chief complaint and present illness was measured by number of words in Korean and normalised bytes. Change in volume of information was measured by two-way ANOVA and multiple regression analyses, controlling for doctors' gender, age, and grade/year of residents, patients' readmission status, reasons for admission and service department to assess any effect of the introduction of an EMR. Total numbers of paper-based medical records (PMRs) and EMRs for analysis were 1,159 and 1,122, respectively. Forty-three doctors participated in the study. Thirty-one (72%) doctors were less than 30 years of age. Number of words proved a better outcome measure (R²=22 for CC, R²=36 for PI) than normalised bytes (R²=18 for CC, R²=35 for PI) for measuring volume of information. Results showed that the volume of information in the chief complaint and present illness was not decreased after the introduction of the EMR, except when the dependent variable was measured by number of words in the present illness. The study showed that the introduction of the EMR did not reduce the volume of information documented for chief complaint and present illness in inpatient medical records. However, further studies are needed to identify how to control the probable loss of information as showed in present illness measured by number of words.

Data quality of paper health records remain problematic and little is known about mobile health data quality. A semiotic data quality framework is used as an analytical lens to identify the quality of data in care health service provision in resource-restricted communities. A mobile application was developed using a co-design approach. The results of the empirical study indicate data quality problems on the syntactic, semantic, pragmatic and social semiotic levels. The social aspect of data quality is an important contributor of quality associated problems. It is important to consider this human involvement in the capturing and using of data for the value of care data to be fully utilized. With better quality data a better care service can be provided and ultimately resulting in better quality life.

Introduction: The Canadian Perinatal Network (CPN) is a national database focused on threatened very pre-term birth. Women with one or more conditions most commonly associated with very pre-term birth are included if admitted to a participating tertiary perinatal unit at 22 weeks and 0 days to 28 weeks and 6 days., Methods: At BC Women's Hospital and Health Centre, we compared traditional paper-based ward logs and a search of the Canadian Institute for Health Information (CIHI) electronic database of inpatient discharges to identify patients., Results: The study identified 244 women potentially eligible for inclusion in the CPN admitted between April and December 2007. Of the 155 eligible women entered into the CPN database, each method identified a similar number of unique records (142 and 147) not ascertained by the other: 10 (6.4%) by CIHI search and 5 (3.2%) by ward log review. However, CIHI search achieved these results after reviewing fewer records (206 vs. 223) in less time (0.67 vs. 13.6 hours for ward logs)., Conclusion: Either method is appropriate for identification of potential research subjects using gestational age criteria. Although electronic methods are less time-consuming, they cannot be performed until after the patient is discharged and records and charts are reviewed. Each method's advantages and disadvantages will dictate use for a specific project.

Background: Interactive Voice Response Systems (IVRS) and other electronic data collection methods have begun to replace conventional paper diaries as a way to capture daily patient reports. However, these methods have not been compared in head and neck (H&N) cancer patients receiving radiation therapy., Methods: 15 subjects with H&N cancer were asked to complete daily IVRS calls and daily paper diaries during radiation therapy. We compared response consistency and comparative adherence across the two methods., Results: 86.1% (1920/2231) of participants' responses were consistent between IVRS and paper diaries. 79.5% of the expected number of paper diaries were completed, compared to 66.2% of IVRS phone calls., Conclusions: In this pilot study of H&N cancer patients undergoing radiation therapy, concordance was high between responses recorded by paper diaries and IVRS. Although adherence appeared to be higher for the paper diaries, it is possible that they may not have been completed at the proper time.

Changes have recently been passed in the Norwegian legislation, allowing for more exchange of patient information between health personnel. These legal changes came as a result of a long and still ongoing debate concerning the potential conflict between confidentiality issues and patient safety as health care is getting more fragmented. At the same time, an increasing number of patients now make use of their legal right to access their patient record. In this paper, we shed light on some of the reasons why patients request a copy of their record. We report the preliminary results from an interview study in which seventeen patients who have asked for a copy of their patient record following a hospital stay have been interviewed. In our interview study, securing transmission of information between health care workers is one of the main reasons for requesting a copy of the record. We will discuss how this finding might contribute to the ongoing debate.

How does paper usage change following the introduction of Computerized Physician Order Entry and the Electronic Medical Record (EMR/CPOE)? To answer that question we analyzed data collected from fourteen sites across the U.S. We found paper in widespread use in all institutions we studied. Analysis revealed psychological, ergonomic, technological, and regulatory reasons for the persistence of paper in an electronic environment. Paper has unique attributes allowing it to fill gaps in information timeliness, availability, and reliability in pursuit of improved patient care. Creative uses have led to "better paper."

While physician informational needs have been examined in the literature, rarely do the findings have the specificity required to drive development of Electronic Medical Records (EMRs) features. Using Delphi methodology, a comprehensive list of desirable, ranked EMR features was developed for physician residency practices. The identified EMR features and implications for system development are explored in this paper.