Paper versus computer: feasibility of an electronic medical record in general pediatrics.
BACKGROUND
Implementation of electronic medical record systems promises significant advances in patient care, because such systems enhance readability, availability, and data quality. Structured data entry (SDE) applications can prompt for completeness, provide greater accuracy and better ordering for searching and retrieval, and permit validity checks for data quality monitoring, research, and especially decision support. A generic SDE application (OpenSDE) to support documentation of patient history and physical examination findings was developed and tailored for the domain of general pediatrics.


OBJECTIVE
To evaluate OpenSDE for its completeness, uniformity of reporting, and usability in general pediatrics.


METHODS
Four (trainee) pediatricians documented data for 8 first-visit patients in the traditional, paper-based, medical record and immediately thereafter in OpenSDE (electronic record). The 32 paper records obtained served as the common data source for data entry in OpenSDE by the other 3 physicians (transcribed record). Data entered by 2 experienced users, with all patient information present in the paper record, served as the control record. Data entry times were recorded, and a questionnaire was used to assess users' experiences with OpenSDE.


RESULTS
Clinicians documented 44% of all available patient information identically in the paper and electronic records. Twenty-five percent of all patient information was documented only in the paper record, and 31% was present only in the electronic record. Differences were found in patient history and physical examination documentation in the electronic record; more information was missing for patient history (38%) than for physical examination (15%). Furthermore, physical examination contained more additional information (39%) than did patient history (21%). The interobserver agreement of documentation of patient information from the same data source was fair to moderate, with kappa values of 0.39 for patient history and 0.40 for physical examination. Data entry times in OpenSDE decreased from 25 minutes to <15 minutes, indicating a learning effect. The questionnaire revealed a positive attitude toward the use of OpenSDE in daily practice.


CONCLUSIONS
OpenSDE seems to be a promising application for the support of physician data entry in general pediatrics.
Roukema
Jolt
J
Department of Pediatrics, Sophia Children's Hospital, Rotterdam, The Netherlands. j.roukema@erasmusmc.nl
Los
Renske K
RK
Bleeker
Sacha E
SE
van Ginneken
Astrid M
AM
van der Lei
Johan
J
Moll
Henriette A
HA
D004282:Documentation; D006801:Humans; D007231:Infant, Newborn; D008487:Medical History Taking; D016347:Medical Records Systems, Computerized; D010372:Pediatrics; D010808:Physical Examination