The impact of electronic medical records on clinical documentation: A case study

Abstract

BACKGROUND:

The introduction of electronic medical records (EMRs) has transformed healthcare documentation practices, offering potential improvements in the quality and efficiency of clinical documentation. As EMR adoption becomes more widespread, there is a growing need to understand its impact on clinical documentation practices. This article addresses this gap by presenting a comprehensive case study that examines the influence of EMRs on clinical documentation within a specific healthcare setting.

MATERIALS AND METHODS:

The researchers developed an EMR system by using various technologies and implemented it in the VIP department of Shahid Madani Hospital at Tabriz University of Medical Sciences. To ensure successful implementation, comprehensive training was provided to department personnel, and necessary equipment was supplied. The impact of the system on clinical documentation processes was evaluated based on AHIMA data characteristics through a comparison of paper and electronic records. Healthcare provider satisfaction was evaluated using an Electronic Health Record End-User Survey questionnaire. Data analysis was conducted using SPSS and Excel.

RESULTS:

The research examined 351 files to assess the effects of introducing EMRs on clinical documentation procedures and user contentment. Findings revealed that EMRs led to an average time saving of 75 minutes in clinical documentation. Moreover, there was a significant enhancement in the quality of documentation, as indicated by the correlation coefficient (P < 0.016). The average system quality score of 4.64 suggested an acceptable level.

CONCLUSION:

High-quality clinical documentation is essential for patient care, and healthcare professionals must strive for the highest standards. While educational campaigns are somewhat effective, the introduction of EMRs significantly improved clinical documentation standards to 100% in all areas. Customizing the EMR to meet end-user needs and utilizing outcome measures will ensure ongoing improvement in clinical documentation standards.

Introduction

The introduction of electronic medical records (EMRs) has marked a significant shift in healthcare documentation practices, replacing traditional paper-based records with digital systems.[1] EMRs offer healthcare providers a centralized platform for storing, managing, and accessing patient information, with the potential to improve the quality, accuracy, and efficiency of clinical documentation.[2] As the adoption of EMRs becomes increasingly prevalent in healthcare settings, there is a growing need to comprehensively understand their impact on clinical documentation practices.[3]

Clinical documentation refers to the comprehensive and detailed recording of a patient’s medical information, treatment, and care provided during their stay in a healthcare facility, such as a hospital. This documentation includes a wide range of data, such as medical history, physical examinations, diagnostic test results, treatment plans, medications administered, progress notes, nursing assessments, consultations, and discharge summaries.[4] Clinical documentation serves as a critical tool for healthcare providers to track and communicate a patient’s condition, treatment course, and response to interventions. It ensures continuity of care, facilitates interdisciplinary communication among healthcare team members, supports clinical decision-making, and provides a legal and regulatory record of the care provided.[5] The transition from paper-based to electronic documentation systems has raised important questions about how EMRs influence the quality, accuracy, and workflow of clinical documentation.[6]

Numerous studies have explored the benefits of EMRs, such as improved access to patient information, reduced errors in medication management, and enhanced coordination of care.[7] However, the impact of EMRs on clinical documentation practices remains a complex and evolving area of inquiry.[8] Healthcare professionals have reported both positive and negative effects of EMRs on clinical documentation, highlighting the need for in-depth analysis and case studies to better understand the implications of these systems.[9]

This manuscript seeks to address this gap in the literature by presenting a comprehensive case study that examines the impact of EMRs on clinical documentation within a specific healthcare setting. By delving into the experiences and perspectives of healthcare professionals, this case study aims to provide a nuanced understanding of how EMRs have influenced clinical documentation practices, the challenges encountered, and the potential benefits realized.

Through a thorough examination of the case study, this manuscript aims to contribute to the existing body of knowledge on the subject, offering valuable insights that can inform best practices for healthcare documentation in the context of EMR adoption. By providing a comprehensive background on the impact of EMRs on clinical documentation, this case study aims to facilitate informed decision-making and promote improvements in healthcare documentation practices, ultimately benefiting both healthcare providers and patients.

Materials and Methods

Study design and setting

This cross-sectional descriptive-analytical study was conducted in 2023. First, the information requirements of the EMR were determined based on the library resources and the expert panels. Then, leveraging MVC Core technology, the EMR database was established using SQL Server 2019. The logic and business layer of the system were coded within the ASP.NET Core environment of Visual Studio 2022 by using the C# language. In addition, the user interface of the system was developed using the ASP.NET Core environment of Visual Studio 2022, incorporating HTML, CSS, Bootstrap, and JavaScript languages. The developed EMR includes various features such as structured information recording and access, a reporting system, management dashboard, web-based, speech recognition, electronic signature, output generation, interoperability capabilities, and modularity. The system was built based on standards, namely ICD-10, ICD-9-CM, LOINC, ATC/DDD, SNOMED-CT, DICOM, HL7, ASTM, HIPAA, CDA, and open EHR.

This system was implemented in the VIP department of Shahid Madani Hospital at Tabriz University of Medical Sciences over a 2-month period, from June 22, 2023, to August 22, 2023. To ensure successful implementation, all VIP department personnel at Shahid Madani Hospital received comprehensive training through educational workshops to familiarize them with the EMR system. In addition, the necessary equipment, including computers, smart tablets, browsers, access points, network cables, optical fibers, switches, domains, and servers, was provided.

For each healthcare provider individually, a dedicated user account with controlled access levels was created based on their role within the healthcare organization. When the provider visits the treatment department, they retrieve a smart device from the carrier trolley and proceed to the patient’s bedside. Then, the provider logs into the system by using a username, password, and a confirmation SMS (two-step verification). On the main page, the list of hospitalized patients is displayed, from which the provider selects their assigned patient. This selection allows the provider to access the patient’s previous information and subsequently input new information into the EMR system. In addition, the provider can search for a specific patient by entering the patient’s national code in the search box or by scanning the barcode on the patient’s wristband. It is important to note that only currently admitted patients are listed in the patient search, and discharged patients can be retrieved through a search function. After selecting the desired patient, each module of the EMR related to the service provided to the patient is completed by the respective providers, depending on the type of service. EMR modules include informed consent, unit summary, medical history and physical examination, progress note, consultation, pre-surgery information, anesthesia, surgery report, recovery information, orders, nursing reports, and paraclinic and previous medical records. It is important to note that the ability to input information is only accessible to hospitalized patients. Once a patient is discharged, it is no longer possible to input new information into the patient’s file; only viewing access is permitted, and solely for authorized personnel.

Study participants and sampling

After implementing the EMR system, its impact on clinical documentation processes was evaluated based on AHIMA data characteristics guidelines such as documentation time, comprehensiveness, relevancy, precision, accuracy, readability, granularity, consistency, and completeness.[10] The study population for this part consisted of the medical records of the patients. The research sample included medical records from June 22, 2023, to August 22, 2023, totaling 351 files. In addition, healthcare providers who had utilized the EMR system were evaluated for their satisfaction with the system. The participants in this study were healthcare providers. The research sample comprised 97 individuals selected using the Krejcie and Morgan method, as well as the simple random sampling method.

Data collection tool and technique

To assess the documentation time, we examined data from patients with cardiovascular diseases who visited the VIP department of Shahid Madani Hospital in Tabriz, Iran, during the 2-month period after the system was implemented. Healthcare providers recorded this data simultaneously in paper-based medical records and EMRs. We then evaluated the collected data and time index.

To assess comprehensiveness, relevancy, precision, accuracy, readability, granularity, consistency, and completeness, two assessors reviewed and evaluated the paper documents from before the implementation of the EMR and the electronic documents from after the implementation. This comparison was used to gauge the effectiveness of the EMR system. For the computation of these metrics, we used the following equation, which can be applied to all indicators:

Furthermore, to assess the satisfaction of healthcare providers, we employed the Electronic Health Record End-User Survey standard questionnaire, which provides a comprehensive overview of user experiences.[11] The researchers distributed this questionnaire among the study participants. The gathered data were input into SPSS version 24 for analysis using descriptive and analytical (correlation coefficient) statistical methods.

Ethical consideration

All the methods were performed in accordance with relevant guidelines and regulations. Before the study was conducted, all participants received information statement about the study and provided written consent to participate. This study was approved by the Ethics Committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1401.488).

Results

After the system was implemented, 351 files were analyzed to assess the impact of EMR implementation on clinical documentation processes. As shown in Table 1, the use of EMRs resulted in an average saving of 75 minutes in clinical documentation time. Furthermore, using this method, data comprehensiveness stands at 22.53%, data relevancy at 10.77%, data precision at 20.06%, data accuracy at 19.04%, data readability at 28.41%, data granularity at 20.66%, data consistency at 11.79%, and data completeness improved by 18.62%. The doctors showed the most significant improvement in the quality of their documentation among all the professionals [Table 2].

Table 1.

The impact of implementing the electronic medical record on the characteristics of the data

Data characteristics		Paper-based		EMR		Measure		P
Documentation time		120		45		Mean (minutes)		0.013
Comprehensiveness		77.47		100		Percent		0.001
Relevancy		89.23		100		Percent		0.03
Precision		79.94		100		Percent		0.023
Accuracy		80.96		100		Percent		0.015
Readability		71.59		100		Percent		0.001
Granularity		79.34		100		Percent		0.012
Consistency		88.21		100		Percent		0.032
Completeness		81.38		100		Percent		0.031

Table 2.

Improvement of documentation quality among professionals after electronic medical record implementing

Documentation quality		Paper-based		EMR		Measure		P
Physicians		76.54		100		Percent		0.003
Nurses		89.47		100		Percent		0.021
Medical Office Assistants		92.23		100		Percent		0.043

As the correlation coefficient shows, the use of EMR had a significant change in improving the quality of documentation (P < 0.016). Figure 1 provides an illustration of clinical documentation in paper medical records compared to EMR systems.

Figure 1.

Example of clinical documentation on paper medical record versus electronic medical record systems

Users’ evaluation of the system using the Electronic Health Record End-User Survey tool revealed an overall score of 4.64 out of 5, indicating highly efficient use of the EMR system [Table 3]. While conducting the survey, respondents were also asked for their opinions on the advantages and disadvantages of electronic notes [Figure 2]. This qualitative data was crucial for identifying potential issues early and addressing them promptly.

Table 3.

Results of the system evaluation by users using the Electronic Health Record End User Survey tool

Evaluation aspect		Range		Average score		Number of questions
Experience		Much worse–Much better		4.8		8
Environment		Strongly disagree–Strongly agree		4.75		19
Impact		Highly detrimental–Highly beneficial		4.66		16
General evaluation		Strongly disagree–Strongly agree		4.42		9
Performance		Very difficult–Very easy		4.60		18

Figure 2.

Benefits and challenges of electronic medical record implementation

Discussion

The results showed that electronic health records resulted in an average time savings of 75 minutes in clinical documentation. In addition, there was a notable improvement in the quality of documentation, as evidenced by the correlation coefficient (P < 0.016).

EMRs are known to improve the quality of documentation in healthcare for several reasons. First, EMRs provide a standardized and organized format for recording patient information, which reduces the likelihood of errors or omissions in documentation. This standardized format also makes it easier for healthcare providers to access and review patient records, leading to more accurate and comprehensive documentation.[12] In addition, EMRs often include built-in prompts and templates that guide healthcare providers in documenting all relevant information during patient encounters. This helps ensure that important details are not overlooked, leading to more thorough and complete documentation.[13]

Moreover, EMRs can facilitate real-time documentation, allowing healthcare providers to enter information directly into the system during patient visits. This immediate recording of data can lead to more accurate and timely documentation, as well as reducing the risk of information being lost or forgotten.[14] Furthermore, EMRs often include features such as automated alerts and reminders for follow-up care, medication management, and preventive screenings, which can help healthcare providers stay on top of documentation and ensure that all necessary information is recorded.[15]

In this research, doctors demonstrated the most notable enhancement in the quality of their documentation compared to other professionals. This phenomenon can be attributed to several factors.

First, variances in documentation guidelines concerning patient safety and quality standards, as well as differences in defining tasks categorized as documentation tasks across studies, may lead to differences in outcomes.[7] Second, doctors often have a higher level of engagement with EMR systems due to their central role in patient care. As primary decision-makers in clinical settings, doctors have a vested interest in ensuring that their documentation accurately reflects patient encounters, diagnoses, treatments, and outcomes. This heightened involvement and ownership of the documentation process can lead to a greater commitment to thorough and precise record-keeping.[16] Third, doctors typically receive extensive training and support in utilizing EMR systems effectively. Their familiarity with medical terminology, diagnostic codes, and treatment protocols enables them to navigate EMR interfaces more adeptly, leading to more comprehensive and accurate documentation.[17]

Furthermore, the nature of doctors’ responsibilities often necessitates detailed and thorough documentation for legal, regulatory, and continuity of care purposes. As such, doctors are motivated to ensure that their documentation is comprehensive, clear, and compliant with professional standards, which can result in a higher quality of documentation compared to other healthcare professionals.[18] In addition, the use of EMR-enabled computerized decision support systems, as highlighted in the referenced study by Scott IA et al.,[15] can further enhance doctors’ documentation quality. These systems provide real-time prompts, alerts, and evidence-based guidelines to support clinical decision-making and documentation, thereby improving the accuracy and completeness of doctors’ records. Overall, the combination of doctors’ active engagement, specialized training, professional responsibilities, and the support of EMR-enabled decision support systems contributes to the notable enhancement in the quality of documentation demonstrated by doctors in EMR implementation compared to other healthcare professionals.

The Electronic Medical Record End User Survey is crucial for several reasons in the context of healthcare and technology. This survey is designed to gather feedback and insights directly from the individuals who use EMR systems in their daily work, typically healthcare providers and staff. The significance of the EMR End User Survey can be understood through the following points:

User experience improvement

The survey provides valuable feedback on the usability and functionality of the EMR system from those who interact with it regularly. This feedback is essential for identifying areas of improvement, addressing usability issues, and enhancing the overall user experience. By understanding end users’ perspectives, healthcare organizations and EMR vendors can make targeted improvements to the system, leading to better workflow efficiency and user satisfaction.[19]

Workflow optimization

End users are in the best position to provide insights into how the EMR system impacts their daily workflows. The survey can reveal inefficiencies, bottlenecks, and areas where the EMR system may not align with clinical processes. Understanding these challenges is essential for optimizing workflows, streamlining documentation processes, and ensuring that the EMR system supports, rather than hinders, clinical operations.[20]

Identifying training needs

The survey helps in identifying specific areas where end users may require additional training or support. By understanding the challenges faced by users, healthcare organizations can tailor training programs to address specific needs, ensuring that staff are proficient in using the EMR system effectively. This, in turn, can lead to improved data accuracy, better utilization of system features, and ultimately, enhanced patient care.[21]

Patient safety and quality of care

Feedback from end users can shed light on how the EMR system impacts patient safety and the quality of care. Identifying issues such as alert fatigue, medication reconciliation challenges, or documentation errors can help in refining the EMR system to better support clinical decision-making and patient outcomes.[22]

Vendor performance evaluation

For healthcare organizations, the EMR End User Survey serves as a tool for evaluating the performance of EMR vendors. It provides insights into the responsiveness of vendors to user feedback, the effectiveness of support services, and the vendor’s commitment to ongoing improvement. This information is valuable when making decisions about system upgrades, vendor partnerships, or potential system replacements. In conclusion, by prioritizing the perspectives of end users, healthcare organizations can ensure that their EMR systems effectively support the delivery of high-quality, efficient, and patient-centered care.[23]

Increasing the quality of documentation through EMRs can have a positive impact on various hospital processes. EMRs allow for easy sharing and access to patient information among healthcare providers, leading to better communication and coordination of care. This can help streamline processes such as referrals, consultations, and handoffs between different departments.[24] Accurate and comprehensive documentation in EMRs can help reduce errors in medication administration, treatment planning, and other aspects of patient care. This can improve patient safety and reduce the risk of adverse events. EMRs can streamline administrative processes such as scheduling, billing, and coding, leading to increased efficiency and productivity. This can help healthcare providers save time and focus more on patient care.[25]

Access to comprehensive and up-to-date patient information through EMR systems can help healthcare providers make more informed decisions about diagnosis, treatment, and follow-up care. This can improve the quality of care and patient outcomes. EMR systems provide a wealth of data that can be used for research, quality improvement initiatives, and population health management. By analyzing this data, hospitals can identify trends, track outcomes, and make evidence-based decisions to improve patient care. Overall, increasing the quality of documentation through EMRs can lead to a more efficient, safe, and effective healthcare system, benefiting both patients and healthcare providers.[26]

However, alongside these benefits, there are several obstacles and challenges that healthcare organizations need to consider when implementing an EMR system. These obstacles are critical to address as they can impact the successful adoption and utilization of the system. The following points provide a comprehensive discussion of the obstacles associated with the introduction of an EMR system:

Financial investment

Implementing an EMR system requires a significant financial investment. This includes the initial cost of purchasing the system, as well as ongoing expenses related to maintenance, upgrades, and support. Healthcare organizations need to carefully consider the financial implications and ensure that they have the resources to sustain the system in the long term.[27]

Training and change management

Transitioning to an EMR system necessitates comprehensive training for healthcare staff to ensure they are proficient in using the new technology. In addition, managing change resistance among staff members who may be accustomed to traditional paper-based processes can be a significant challenge. Effective change management strategies are essential to facilitate a smooth transition and minimize disruptions in clinical workflows.[28]

Workflow disruption

The introduction of an EMR system can initially disrupt clinical workflows as staff members adapt to new documentation processes and system interfaces. This disruption can impact productivity and potentially lead to temporary decreases in efficiency. Healthcare organizations must proactively address workflow challenges to minimize the impact on patient care and operational efficiency.[29]

Data migration and integration

Transitioning from paper-based records to an EMR system involves the complex task of migrating existing patient data into the new electronic format. Ensuring accurate data migration and seamless integration with other systems (e.g., laboratory systems and billing systems) is essential to maintain data integrity and continuity of care.[30]

Interoperability and data exchange

Achieving interoperability between different EMR systems and enabling seamless data exchange with external healthcare providers and organizations is a significant obstacle. Inconsistent data formats, lack of standardized protocols, and privacy concerns can hinder the efficient sharing of patient information, impacting care coordination and continuity.[31]

Data security and privacy

EMR systems store sensitive patient information, making data security and privacy a paramount concern. Healthcare organizations must implement robust security measures to safeguard patient data from unauthorized access, cyber threats, and data breaches, while also ensuring compliance with privacy regulations such as HIPAA.[32]

User experience and satisfaction

The usability of EMR systems can significantly impact user experience and satisfaction. Complex interfaces, cumbersome documentation processes, and inefficient system navigation can lead to user frustration and dissatisfaction. Prioritizing user-centered design and ongoing user feedback is essential to address usability issues and enhance user satisfaction.[33]

Regulatory compliance

Healthcare organizations must ensure that their EMR systems comply with regulatory requirements and standards, such as meaningful use criteria, quality reporting, and documentation standards. Navigating the evolving regulatory landscape and staying abreast of compliance requirements can be a complex undertaking. In conclusion, while the introduction of an EMR system offers substantial benefits, it is crucial for healthcare organizations to recognize and address the obstacles associated with implementation. By proactively addressing financial, technical, operational, and regulatory challenges, healthcare organizations can maximize the potential of EMR systems to improve patient care, streamline processes, and advance the quality and safety of healthcare delivery.[34]

Limitation and recommendation

The study was conducted at a public specialized and super-specialized cardiovascular hospital; thus, the findings are restricted and may not be generalizable to all hospitals due to variations in clinical situations among public and private, large and small, general and specialized hospitals. As a result, it is recommended that this study be replicated in other hospital settings.

Conclusion

The implementation of EMRs has brought about tangible benefits in terms of time savings, data quality improvements, professional impact, high user satisfaction, and qualitative feedback, as evidenced by the analysis of 351 files. By leveraging these findings and addressing user feedback, healthcare organizations can continue to enhance their clinical documentation processes and optimize the use of EMR systems for improved patient care and outcomes. High-quality clinical documentation is crucial for the care of patients. Therefore, as healthcare professionals, it is essential for us to aim for the highest standards of clinical documentation.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.