The implementation of an electronic medical record (EMR) and its impact on quality of documentation

Abstract Background The German healthcare system is still poorly digitized. With the Hospital Future Act, the government now mandates hospitals to implement an institutional electronic medical record (EMR). While multiple benefits are described for its adoption, knowledge on its impact on actual documentation is lacking. However, a documentation that is of good quality is, additionally to its patient safety aspect, required to enable benefits such as big data analyzability. The completeness of documentation is a dimension of quality most often researched in this context. The purpose of the present study is therefore to analyze a change in completeness of documentation after the implementation of an EMR. Methods Data were collected on an orthopaedical ward of a German academic teaching hospital before and after the implementation of the EMR. Paper-based and electronic medical records were compared, each representing all treated patients of a three-week period. Our analysis focused on ten items that were commonly documented in both record types (e.g. documentation of pain). T-tests, χ2-tests and Odds Ratios were calculated to compare the average completeness per record type and the percentage of completeness per item. Results A total of N = 180 records were analyzed. Average completeness rose from 6.25 out of 10 (SD = 2.15) in the paper-based record type to 7.13 (SD = 2.01) in the electronic record type (p=.014). Of the ten analyzed items, three showed higher rates of completeness and another three lower rates of completeness in the EMR. Four items retained a constant rate of completeness in both record types. Conclusions The implementation of an EMR can influence the quality of documentation with both, positive and negative impacts. Further research is needed on what determines the direction of the impact. Doing so could make it feasible to increase quality of documentation and simultaneously reduce staff's burden caused by documentational tasks. Key messages • The present study strengthens evidence, that implementing an institutional electronic medical record can have an impact on the quality of clinical documentation in the inpatient setting. • Understanding the mechanisms influencing documentation could help increase the quality of documentation and reduce the burden caused by documentational tasks at the same time.