Physicians document progress notes more accurately in paper charts than in electronic health records (EHRs), according to one study published in the Journal of the American Medical Informatics Association. However, physicians are more likely to omit information in paper progress notes compared to progress notes documented in the EHRs, the study found.
Researchers at Beaumont Hospital-Royal Oak in Michigan retrospectively reviewed 500 progress notes from patients with five specific diagnoses admitted to the hospital between August 2011 and July 2013. 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.
According to the study, 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.
The researchers were looking to address concerns about the quality of documentation in EHRs when compared to paper charts.
The study findings indicated that the rate of inaccurate documentation was significantly higher in the EHRs compared to the paper charts, 24 percent versus 4 percent, respectively. However, the study also found that documentation in EHRs is more thorough, with expected physical examination findings more likely to be omitted in the paper notes, at 41 percent, compared to EHRs, at 17 percent.
The study findings also concluded that resident physicians had a smaller number of inaccuracies (5 percent versus 17 percent) and omissions (16 percent vs 33 percent) compared to attending physicians.
The researchers concluded, according to the study abstract, that during the initial phase of implementation of an EHR, inaccuracies were more common in progress notes in the EHR compared to the paper charts. “Further research is needed to identify training methods and incentives that can reduce inaccuracies in EHRs during initial implementation,” the study authors wrote.
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