The electronic patient record in primary care--regression or progression? A cross sectional study

Abstract

Objectives: To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve.

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

Setting: 25 general practices in Trent region.

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

Main outcome measures: 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).

Conclusion: 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.