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First published June 4, 2003 as JAMIA PrePrint; doi:10.1197/jamia.M1290
Journal of the American Medical Informatics Association 2003;10(5):470-477
© 2003 American Medical Informatics Association

A more recent version of this article appeared on September 1, 2003
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Submitted on November 11, 2002
Accepted on April 19, 2003

Comparing paper-based to electronic patient records: lessons learned during a study on diagnosis and procedure codes

Juergen Stausberg Priv.-Doz. Dr. med.1*, Dietrich Koch2, Josef Ingenerf Dr. rer. nat3, and Michael Betzler Prof. Dr. med.2

Affiliation of the authors: 1 Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University of Duisburg-Essen, Germany; 2 Department of General, Trauma, and Vascular Surgery, Alfried Krupp Hospital, Essen, Germany; 3 Institute for Medical Informatics, University of Luebeck, Germany

* To whom correspondence should be addressed.

Paper-based and electronic patient records are generally used in parallel to support different tasks. Many studies comparing their quality do not report sufficiently on the methods used. Few studies refer to the patient. Instead, most regard the paper record as the gold standard. Focusing on quality criteria, the present study compared the two records patient-by-patient, presuming that each might hold unique advantages. For surgical patients at a non-university hospital, diagnosis and procedure codes from the hospital's electronic patient record (EPR-set) were compared to the paper records (PPR-set). Diagnoses coding from the paper-based patient record resulted in minor qualitative advantages. The EPR-documentation showed potential advantages in both quality and quantity of procedure coding. As in many previous studies, the current study relied on a single individual to extract and transform contents from the paper record to compare PPR to EPR. The exploratory study, though limited, supports previous views of the complementary nature of paper and electronic records. The lessons learned from this study are that medical professionals should be cognizant of the possible discrepancies between paper and electronic information, and look toward combining information from both records whenever appropriate. The inadequate methodology (transformations done by a single individual) employed in the author's study is typical of other studies in the field. The limited generality and restricted reproducibility of this commonly used approach emphasizes the need to improve methods for comparing paper-based to electronic versions of a patient's chart.




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