The electronic patient record in primary care--regression or progression? A cross sectional study.
OBJECTIVE
To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve.


METHODS
Cross sectional study with review of medical records and interviews with general practitioners.


METHODS
25 general practices in Trent region.


METHODS
53 British general practitioners (25 using paperless records and 28 using paper based records) who each provided records of 10 consultations.


METHODS
Content of a sample of records and doctor recall of consultations for which paperless or paper based records had been made.


RESULTS
Compared with paper based records, more paperless records were fully understandable (89.2% v 69.9%, P=0.0001) and fully legible (100% v 64.3%, P < 0.0001). Paperless records were significantly more likely to have at least one diagnosis recorded (48.2% v 33.2%, P=0.05), to record that advice had been given (23.7% vs 10.7%, P=0.017), and, when a referral had been made, were more likely to contain details of the specialty (77.4% v 59.5%, P=0.03). When a prescription had been issued, paperless records were more likely to specify the drug dose (86.6% v 66.2%, P=0.005). Paperless records contained significantly more words, abbreviations, and symbols (P < 0.01 for all). At doctor interview, there was no difference between the groups for the proportion of patients or consultations that could be recalled. Doctors using paperless records were able to recall more advice given to patients (38.6% v 26.8%, P=0.03).


CONCLUSIONS
We found no evidence to support our hypotheses that paperless records would be truncated and contain more local abbreviations; and that the absence of writing would decrease subsequent recall. Conversely we found that the paperless records compared favourably with manual records.
Hippisley-Cox
Julia
J
Division of General Practice, Nottingham University, Nottingham NG7 2RD. julia.hippisley-cox@nottingham.ac.uk
Pringle
Mike
M
Cater
Ruth
R
Wynn
Alison
A
Hammersley
Vicky
V
Coupland
Carol
C
Hapgood
Rhydian
R
Horsfield
Peter
P
Teasdale
Sheila
S
Johnson
Christine
C
D000328:Adult; D003430:Cross-Sectional Studies; D011307:Drug Prescriptions; D004739:England; D005194:Family Practice / Q000458:organization & administration*; D005260:Female; D006801:Humans; D019451:Information Management / Q000379:methods; D016247:Information Storage and Retrieval; D007407:Interviews as Topic; D008297:Male; D016347:Medical Records Systems, Computerized / Q000592:standards*; D015588:Observer Variation; D012017:Referral and Consultation / Q000458:organization & administration