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Class 18 Paper Based vs Electronic Based Clinical Records The effects on hospital statistics Class 18 Paper Based vs Electronic Based Clinical Records The effects on hospital statistics

Paper Based vs Electronic Based Clinical Records Introduction ü ü Recording clinical information is Paper Based vs Electronic Based Clinical Records Introduction ü ü Recording clinical information is important to the health industry Access to previous information leads to better diagnosis and treatment in the future [Movig KL, Leufkens HG, Lenderink AW, Egberts AC. Validity of hospital discharge International Classification of Diseases (ICD) codes for identifying patients with hyponatremia. J Clin Epidemiol. 2003 Jun; 56(6): 530 -5. ] ü Paper-based record / Electronic records

Paper Based vs Electronic Based Clinical Records ü Lacks of information of previous studies Paper Based vs Electronic Based Clinical Records ü Lacks of information of previous studies [Movig KL, Leufkens HG, Lenderink AW, Egberts AC. Validity of hospital discharge International Classification of Diseases (ICD) codes for identifying patients with hyponatremia. J Clin Epidemiol. 2003 Jun; 56(6): 530 -5. ] ü Electronic patient record (EPR) as the main method in a near future. [Gillies J, Holt A. Anxious about electronic health records? No need to be. N Z Med J. 2003 Sep 26; 116(1182): U 604. ] ü It is important to study and to conclude if this new information organization will result in any difference from the old one.

Paper Based vs Electronic Based Clinical Records ü Advantages and disadvantages of EPR and Paper Based vs Electronic Based Clinical Records ü Advantages and disadvantages of EPR and paperbased records. Most of the studies conclude that the electronic system is better, although some of them disagree. [ Van der Meijden MJ, Tange HJ, Boiten J, Troost J, Hasman A. An experimental electronic patient record for stroke patients. Part 1: situation analysis. Int J Med Inform. 2000 Sep; 5859: 111 -25]

Paper Based vs Electronic Based Clinical Records ü Main difficulties in the implementation of Paper Based vs Electronic Based Clinical Records ü Main difficulties in the implementation of EPR. [Mohr DN, Carpenter PC, Claus PL, Hagen PT, Karsell PR, Van Scoy RE. Implementing an EMR: paper's last hurrah. Proc Annu Symp Comput Appl Med Care. 1995; : 157 -61. ] ü Negligent data introduction. [Friedman BA. The potential role of physicians in the management of hospital information systems. Clin Lab Med. 1990 Mar; 10(1): 239 -50] ü Typing and visualization speed. [Rodriguez NJ, Murillo V, Borges JA, Ortiz J, Sands DZ. A usability study of physicians interaction with a paper-based patient record system and a graphical-based electronic patient record system. Proc AMIA Symp. 2002; : 667 -71. ]

Paper Based vs Electronic Based Clinical Records ü Coding errors (ICD). [Movig KL, Leufkens Paper Based vs Electronic Based Clinical Records ü Coding errors (ICD). [Movig KL, Leufkens HG, Lenderink AW, Egberts AC. Validity of hospital discharge International Classification of Diseases (ICD) codes for identifying patients with hyponatremia. J Clin Epidemiol. 2003 Jun; 56(6): 530 -5. ] ü Costs and benefits of EPR. [Ellingsen G, Monteiro E. Big is beautiful: electronic patient records in large Norwegian hospitals 1980 s-2001. Methods Inf Med. 2003; 42(4): 366 -70. ] ü Hospital’s economical survival. [Muller ML, Burkle T, Irps S, Roeder N, Prokosch HU. The diagnosis related groups enhanced electronic medical record. Int J Med Inform. 2003 Jul; 70(2 -3): 221 -8. ]

Paper Based vs Electronic Based Clinical Records Objective The main objective is: Quantify the Paper Based vs Electronic Based Clinical Records Objective The main objective is: Quantify the differences among diagnosis and procedures recorded before and after the EPR implementation in the paper-based and the electronicbased methods.

Paper Based vs Electronic Based Clinical Records Methods Participants and Methods ü ü Type Paper Based vs Electronic Based Clinical Records Methods Participants and Methods ü ü Type of study: it is longitudinal and observational We chose two departments to work about (obstetrics and pneumology) and two periods of time (a few months before and after the implementation of EPR) ü We treated two databases on SPSS®, each from one of the departments ü Each database was divided in two periods, before and after the implementation

Paper Based vs Electronic Based Clinical Records Methods – 1 st Period First Period Paper Based vs Electronic Based Clinical Records Methods – 1 st Period First Period ü ü Each DRG code consists on a general code that groups together several diagnoses into one variable Each database was divided in two periods: Before and After EPR Inclusion criteria ü ü We made a selection of the main diagnosis on each department: ü On the obstetrics department we chose those with a minimum number of 20 cases on the sum of both periods ü On the pneumology department we chose those with a minimum number of 10 cases on the sum of both periods We did two kinds of analyses: a qualitative one and a quantitative one.

Paper Based vs Electronic Based Clinical Records Qualitative Analysis ü The qualitative analysis consists Paper Based vs Electronic Based Clinical Records Qualitative Analysis ü The qualitative analysis consists on checking the differences between the GDH before and after the introduction of EPR ü ü By using a statistical test (Chi-square) on SPSS® we have searched for significant differences between GDH from the two groups previously selected After analyzing the differences in a major perspective we decided to check each GDH individually to quantify the differences by using another Chi-square test.

Paper Based vs Electronic Based Clinical Records Quantitative Analysis (it focuses on the number Paper Based vs Electronic Based Clinical Records Quantitative Analysis (it focuses on the number of the diagnosis rather than the type of diagnosis) ü ü We started working with all the diagnosis instead of using only GDH in order to compare the number of diagnosis before and after the implementation The main test used in this case was a Mann-Whitney test

Paper Based vs Electronic Based Clinical Records Methods – nd 2 Period Second Period Paper Based vs Electronic Based Clinical Records Methods – nd 2 Period Second Period ü ü ü The database used in the first period was changed into one that allowed us to check the frequency of each diagnosis/procedure separately. The diagnosis/procedures selected were the fifteen with more cases on the sum of the before and after periods. Using SPSS® the information was analised in two differente ways: ü ü ü General Approach to the data including the 15 diagnosis/procedures, using a chi-square test. Each diagnosis/procedure was checked for differences between the two periods of time, using chi-square tests. Both doctors and coders from both departments were enquired in search for justification for the statistically significant differences found

Paper Based vs Electronic Based Clinical Records Linear Flow Chart Paper Based vs Electronic Based Clinical Records Linear Flow Chart

Paper Based vs Electronic Based Clinical Records Linear Flow Chart Paper Based vs Electronic Based Clinical Records Linear Flow Chart

Paper Based vs Electronic Based Clinical Records Linear Flow Chart Paper Based vs Electronic Based Clinical Records Linear Flow Chart

Paper Based vs Electronic Based Clinical Records Methods Flow Chart Paper Based vs Electronic Based Clinical Records Methods Flow Chart

Paper Based vs Electronic Based Clinical Records Methods Flow Chart Paper Based vs Electronic Based Clinical Records Methods Flow Chart

Paper Based vs Electronic Based Clinical Records Methods Flow Chart Paper Based vs Electronic Based Clinical Records Methods Flow Chart

Paper Based vs Electronic Based Clinical Records Gantt’s Graphic/Chart Paper Based vs Electronic Based Clinical Records Gantt’s Graphic/Chart

Paper Based vs Electronic Based Clinical Records st 1 Period st Period 1 Paper Based vs Electronic Based Clinical Records st 1 Period st Period 1

Paper Based vs Electronic Based Clinical Records Results Departament Before After Obst 887 975 Paper Based vs Electronic Based Clinical Records Results Departament Before After Obst 887 975 Pneumo 292 293 Table 1 - Total number of individuals on both departments, before and after the EPR implementation.

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department GDH code Diagnosis Paper Based vs Electronic Based Clinical Records Results - Obstetrics department GDH code Diagnosis description 362 ENDOSCOPIC TUBAL INTERRUPTION 370 CESAREAN SECTION WITH CC 371 CESAREAN SECTION WITHOUT CC 372 VAGINAL DELIVERY WITH COMPLICATING DIAGNOSES 373 VAGINAL DELIVERY WITHOUT COMPLICATING DIAGNOSES 379 THREATENED ABORTION 380 ABORTION W/O D&C 381 ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY 383 OTHER ANTEPARTUM DIAGNOSES WITH MEDICAL COMPLICATIONS 384 OTHER ANTEPARTUM DIAGNOSES WITHOUT MEDICAL COMPLICATIONS Table 2 – Description of the GDH code from the selected diagnosis. Graph 1 – Comparison between the two groups

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department GDH code Before Paper Based vs Electronic Based Clinical Records Results - Obstetrics department GDH code Before (%) After (%) 362 2, 7 0 370 3, 5 3, 2 371 26, 2 19, 3 372 3, 4 4, 0 373 46, 3 53, 4 379 2, 0 1, 4 380 3, 4 381 2, 9 3, 0 383 1, 6 2, 5 384 4, 7 5, 2 others 3, 6 4, 6 Table 4 – % of each diagnosis on both periods Graph 1 – Comparison between the two groups

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Graph 1 – Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Graph 1 – Comparison between the two groups

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Diagnosis: “Parto Vaginal Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Diagnosis: “Parto Vaginal sem complicações” (GDH 373) In a first phase we searched for general differences in the GDH. Secondly we searched for differences on each individual GDH. This is an example of a GDH where we found statistically significant differences. The other cases are: “Cesariana sem complicações” (GDH 371); and “Laqueação de trompas via laparoscópia” (GDH 362).

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Paper Based vs Electronic Based Clinical Records Results - Obstetrics department

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Although it seems Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Although it seems obvious that this isn’t a normal distribution we decided to confirm by doing an one sample K-S Test.

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Mann-Whitney The 1 Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Mann-Whitney The 1 -sample K-S test confirmed that it wasn’t a normal distribution as p<0, 01 , so it is <0, 05. As it wasn’t a normal distribution we had to do a non-parametric test for two independent variables. As we can see p=0, 861 which is >0, 05, so we accept nule hypothesis.

Paper Based vs Electronic Based Clinical Records Results – Pneumology department GDH code Diagnosis Paper Based vs Electronic Based Clinical Records Results – Pneumology department GDH code Diagnosis description 75 MAJOR CHEST PROCEDURE 76 OTHER RESPIRATORY SYSTEM OR PROCEDURES WITH CC 79 RESPIRATORY INFECTIONS AND INFLAMATIONS, AGE >17, WITH CC 82 RESPIRATORY NEOPLASM 85 PLEURAL EFFUSION WITH CC 88 CHRONIC OBSTRUCTIVE PULMONARY DISEASES 89 PNEUMONIA AGE 18 OR OLDER WITH COMPLICATION, BACTERIAL, VIRAL, AND BRONCHIAL PNEUMONIA AND PLEURISY. 92 94 PNEUMOTHORAX WITH CC 95 PNEUMOTHORAX WITHOUT CC 99 RESPIRATORY SIGND AND SYMPTOMS WITH CC 101 Graph 2 – Comparison between the two groups INTERSTICIAL LUNG DISEASE WITH CC OTHER RESPIRATORY SYSTEM DIAGNOSES W CC 475 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATION SUPPORT Table 5 – Description of the GDH code from the selected diagnosis .

Paper Based vs Electronic Based Clinical Records Results – Pneumology department GDH code Before Paper Based vs Electronic Based Clinical Records Results – Pneumology department GDH code Before (%) After (%) 75 1, 7 2, 7 76 2, 7 2, 1 79 8, 5 6, 8 82 37, 2 26, 7 85 2, 0 2, 1 88 10, 2 11, 6 89 5, 8 7, 5 92 2, 0 2, 1 94 1, 0 3, 1 95 4, 8 5, 1 99 2, 4 2, 7 101 2, 4 5, 8 475 1, 4 2, 4 Others 17, 7 19, 2 Table 7 – % of each diagnosis on both periods Graph 2 – Comparison between the two groups

Paper Based vs Electronic Based Clinical Records Results – Pneumology department Graph 2 – Paper Based vs Electronic Based Clinical Records Results – Pneumology department Graph 2 – Comparison between the two groups

Paper Based vs Electronic Based Clinical Records Results – Pneumology department Diagnosis: “Neoplasias Respiratórias”(GDH Paper Based vs Electronic Based Clinical Records Results – Pneumology department Diagnosis: “Neoplasias Respiratórias”(GDH 82) Regarding pneumology, we followed the same procedure we used for obstretics. We searched for differences both generally and individually for significant GDH’s. Here is one exemple we found. The other significant GDH we found was “Outros diagnósticos de aparelho respiratório complicações” (GDH 101).

Paper Based vs Electronic Based Clinical Records Results – Pneumology department Paper Based vs Electronic Based Clinical Records Results – Pneumology department

Paper Based vs Electronic Based Clinical Records Results – Pneumology department Although it seems Paper Based vs Electronic Based Clinical Records Results – Pneumology department Although it seems obvious that this isn’t a normal distribution we decided to confirm by doing an one sample K-S Test.

Paper Based vs Electronic Based Clinical Records Results – Pneumology department Mann-Whitney The 1 Paper Based vs Electronic Based Clinical Records Results – Pneumology department Mann-Whitney The 1 -sample K-S test confirmed that it wasn’t a normal distribution as p<0, 01 , so it is <0, 05. As it wasn’t a normal distribution we had to do a non-parametric test for two independent variables. As we can see p=0, 084 which is >0, 05, so we accept nule hypothesis.

Paper Based vs Electronic Based Clinical Records 2 nd Period 2 Paper Based vs Electronic Based Clinical Records 2 nd Period 2

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Diagnosis - Obstetrics Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Diagnosis - Obstetrics General (differences were found) Value Asymp. Sig. (2 -sided) df 126, 435( a) 15 , 000 134, 712 15 , 000 Linear-by-Linear Association 9, 705 1 , 002 N of Valid Cases 4728 Pearson Chi-Square Likelihood Ratio a 0 cells (, 0%) have expected count less than 5. The minimum expected count is 24, 56.

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Diagnosis - Obstetrics Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Diagnosis - Obstetrics Diagnosis where differences were found üV 25. 2 - Request for sterillization ü 654. 21 - Previous cesarean section ü 664. 01 – First-degree perineal laceration ü 661. 11 - Secondary uterine inertia ü 648. 21 - Anemia ü 656. 11 - Rhesus isoimmunization

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Procedures - Obstetrics Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Procedures - Obstetrics General (differences were found) Value Asymp. Sig. (2 -sided) df 532, 269( a) 15 , 000 Likelihood Ratio 584, 291 15 , 000 Linear-by-Linear Association 37, 784 1 , 000 N of Valid Cases 8136 Pearson Chi-Square 0 cells (, 0%) have expected count less than 5. The minimum expected count is 58, 69.

Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Procedures - Obstetrics Paper Based vs Electronic Based Clinical Records Results - Obstetrics department Procedures - Obstetrics Procedures where differences were found ü 75. 35 - Other diagnostic procedures on fetus and amnion ü 99. 18 - Injection or infusion of electrolytes ü 73. 59 - Other manually assisted delivery ü 90. 59 - Microscopic examination of blood ü 88. 78 - Diagnostic ultrasound of gravis uterus ü 73. 6 - Episiotomy ü 75. 34 -Fetal monitoring, not otherwise specified ü 99. 29 - Injection or infusion of otherapeutic or prophylactic substance ü 72. 71 -Vacuum extraction with episiotomy ü 93. 57 - Aplication of other wound dressing

Paper Based vs Electronic Based Clinical Records Results - Pneumology department Diagnosis - Pneumology Paper Based vs Electronic Based Clinical Records Results - Pneumology department Diagnosis - Pneumology General (differences were found) Pearson Chi-Square Value Asymp. Sig. (2 -sided) df 26, 081(a) 15 , 037 Likelihood Ratio 26, 158 15 , 036 Linear-by-Linear Association 2, 551 1 , 110 N of Valid Cases 4564 a 0 cells (, 0%) have expected count less than 5. The minimum expected count is 24, 67.

Paper Based vs Electronic Based Clinical Records Results - Pneumology department Diagnosis - Pneumology Paper Based vs Electronic Based Clinical Records Results - Pneumology department Diagnosis - Pneumology Diagnosis where differences were found ü Doenças do aparelho respiratório, NCOP - 519. 8 ü Derrame pleural não especificado - 511. 9 ü Pneumonia devida a microrganismo não especificado - 486

Paper Based vs Electronic Based Clinical Records Results - Pneumology department Procedures - Pneumology Paper Based vs Electronic Based Clinical Records Results - Pneumology department Procedures - Pneumology General (differences were found) Pearson Chi-Square Value Asymp. Sig. (2 -sided) df 23, 089(a) 15 , 082 Likelihood Ratio 23, 157 15 , 081 Linear-by-Linear Association 1, 181 1 , 277 N of Valid Cases 5235 a 0 cells (, 0%) have expected count less than 5. The minimum expected count is 44, 60.

Paper Based vs Electronic Based Clinical Records Results - Pneumology department Procedures - Pneumology Paper Based vs Electronic Based Clinical Records Results - Pneumology department Procedures - Pneumology Procedures where differences were found ü Injecção ou infusão de electrolitos - 99. 18

Paper Based vs Electronic Based Clinical Records Discussion - Obstetrics department Diagnosis - Obstetrics Paper Based vs Electronic Based Clinical Records Discussion - Obstetrics department Diagnosis - Obstetrics Diagnosis where differences were found üAdmissão para esterilização - V 25. 2 The increase in the number of cases, may possibly be justified by the attempt to reduce the practise of episiotomy. üHistória de parto por cesariana, parto referenciado, c/ ou s/ condição anteparto - 654. 21 üLaceração períneo do primeiro grau - 664. 01 üInércia uterina secundária - 661. 11 üAnemia complicando um parto referenciado, com ou sem menção de condição anteparto - 648. 21 üIsoimunização Rh condição anteparto com parto referenciado - 656. 11

Paper Based vs Electronic Based Clinical Records Discussion - Obstetrics department Procedures - Obstetrics Paper Based vs Electronic Based Clinical Records Discussion - Obstetrics department Procedures - Obstetrics Procedures where differences were found üActos de diagnóstico no feto e âmnio NCOP - 75. 35 üParto manual assistido, não classificável em outra parte - 73. 59 Large increase of cases. There are two possible reasons: more available devices; and the existence of a phd theses in course, related to the decrease of the cesarians by non tranquilizer fetal state. it increased because it became indispensable in every case of non tranquilizer fetal state. üExame microscópico NCOP do sangue - 90. 59 üUltra - 88. 78 üEpisiotomia - 73. 6 üMonitorização fetal NCOP - 75. 34 (*) the increase of the registration of this procedures contradicts the increase of the diagnose 664. 01 (Laceração do perínio do primeiro grau). We found no explanation for this fact. üExtracção por ventosa com episiotomia - 72. 71 üInjecção ou infusão de electrolitos - 99. 18 üInjecção ou infusão de substancia terapêutica - 99. 29 üAplicação de outros pensos para feridas - 93. 57 The decrease of this three procedures are the result of an intentional reduction of the registration of this kind of methods, because they are a kind of procedure that is done in almost every treatment and it not necessary neither useful to keep this type of information.

Paper Based vs Electronic Based Clinical Records Discussion - Pneumology department Diagnosis - Pneumology Paper Based vs Electronic Based Clinical Records Discussion - Pneumology department Diagnosis - Pneumology Diagnosis where differences were found ü Doenças do aparelho respiratório, NCOP - 519. 8 ü Derrame pleural não especificado - 511. 9 ü Pneumonia devida a microrganismo não especificado - 486 The increase of this diagnoses is related to the management of the distribution of the patients between departments. The patients were usually randomly distributed between the internal medicine and the pneumology departments. But recently, the pneumology department is taking care of the delicated cases, like the ones above, which justifies the difference found.

Paper Based vs Electronic Based Clinical Records Discussion – Pneumology department Procedures - Pneumology Paper Based vs Electronic Based Clinical Records Discussion – Pneumology department Procedures - Pneumology Procedures where differences were found ü Injecção ou infusão de electrolitos - 99. 18 The decrease of this procedure is the result of an intentional reduction of the registration of this kind of methods, because they are a kind of procedure that is done in almost every treatment and it not necessary neither useful to keep this type of information.

Diagnosis/Procedures Code Increase/ Decrease % Diagnosis Obstetrics Request for sterillization V 25. 2 Decrease Diagnosis/Procedures Code Increase/ Decrease % Diagnosis Obstetrics Request for sterillization V 25. 2 Decrease -64, 29% Previous cesarean section 654. 21 Decrease -48, 28% First-degree perineal laceration 664. 01 Increase 84, 6 2% Secondary uterine inertia 661. 11 Decrease -88, 89% Anemia 648. 21 Decrease -50, 00% Rhesus isoimmunization 656. 11 Increase 14, 06% Procedures Obstetrics 75. 35 Increase 48, 1 9% 73. 59 Increase 43, 06% Other diagnostic procedures on fetus and amnion Other manually assisted delivery 35, 5 9% Microscopic examination of blood 90. 59 Increase Diagnostic ultrasound of gravis uterus 88. 78 Increase 42, 31% Episiotomy 73. 6 Increase 25, 4 2% Fetal monitoring, not otherwise specified 75. 34 Increase 21, 43% Vacuum extraction with episiotomy 72. 71 Increase 37, 93% Injection or infusion of electrolytes 99. 18 Decrease -73, 68% Injection or infusion of otherapeutic or prophylactic substance 99. 29 Decrease -53, 62% Aplication of other wound dressing 93. 57 Decrease Diagnosis Pneumology 96, 43 % 47, 3 7% Other diseases of respiratory system, not elsewhere classified 519. 8 Increase Unspecified pleural effusion 511. 9 Increase 55, 56% Pneumonia, organism unspecified 486 Increase 88, 89% Procedures Pneumology

Paper Based vs Electronic Based Clinical Records Aknowledgments We would like to thank the Paper Based vs Electronic Based Clinical Records Aknowledgments We would like to thank the professors Ricardo Correia, Cristina Santos and Clara Tavares, without whose help we would not be able to finish our work. We are also grateful to Dr. Fernando Lopes, responsible EPR codification, Dra. Ana Rosa and Dra. Raquel Mota, from the obstetrics department, and finally Dr. Agostinho Marques, from the pneumology department. Finally, we would like to thank to Professor Altamiro, for his precious help and guidance throughout the year.