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

2. Introduction 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.] Paper-based record / Electronic records Paper Based vs Electronic Based Clinical Records

3. 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.] 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):U604.] 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

4. Advantages and disadvantages of EPR and paper- based 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;58- 59:111-25] Paper Based vs Electronic Based Clinical Records

5. 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.] 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] 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

6. 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.] Costs and benefits of EPR. [Ellingsen G, Monteiro E. Big is beautiful: electronic patient records in large Norwegian hospitals 1980s-2001. Methods Inf Med. 2003;42(4):366-70.] 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

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

8. Methods T ype 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) We treated two databases on SPSS®, each from one of the departments Each database was divided in two periods, before and after the implementation Paper Based vs Electronic Based Clinical Records

9. We made a selection of the main diagnosis on each department: On the obstetrics department we chose those with a minimum number of 20 cases on the sum of both periods 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

10. Qualitative Analysis The qualitative analysis consists on checking the differences between the GDH before and after the introduction of EPR 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

11. Quantitative Analysis (it focuses on the number of the diagnosis rather than the type of diagnosis) 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

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

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

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

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

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

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

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

19. Results Paper Based vs Electronic Based Clinical Records DepartamentBeforeAfter Obst887975 Pneumo292293 Table 1 - Total number of individuals on both departments, before and after the EPR implementation.

20. Results - Obstetrics department Graph 1 – Comparison between the two groups GDH code Diagnosis description 362Laqueação de trompas, via laparoscópica 370Cesariana com Complicações e/ou Comorbilidades 371Cesariana sem Complicações e/ou Comorbilidades 372Parto vaginal com diagnóstico de complicação 373Parto vaginal sem diagnóstico de complicação 379Ameaça de aborto 380Aborto sem dilatação e curetagem 381Aborto com dilatação e curetagem, curetagem aspirativa ou histerotomia 383Outros diagnósticos pré-parto com complicações médicas 384Outros diagnósticos pré-parto sem complicações médicas Table 2 – Description of the GDH code from the selected diagnosis. Paper Based vs Electronic Based Clinical Records

21. Results - Obstetrics department Paper Based vs Electronic Based Clinical Records Graph 1 – Comparison between the two groups Table 4 – % of each diagnosis on both periods GDH cod e Before (%)After (%) 3622,70 3703,53,2 37126,219,3 3723,44,0 37346,353,4 3792,01,4 3803,03,4 3812,93,0 3831,62,5 3844,75,2 others3,64,6

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

23. Results - Obstetrics department Paper Based vs Electronic Based Clinical Records Diagnosis: “Parto Vaginal sem complicações” (GDH373) 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” (GDH371); and “Laqueação de trompas via laparoscópia” (GDH362).

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

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

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

27. Results – Pneumology department Paper Based vs Electronic Based Clinical Records GDH codeDiagnosis description 75Grandes intervenções torácicas 76Outras intervenções no aparelho respiratório no Bloco Operatório, c/CC 79Infecções e inflamações respiratórias, Idade > 17 anos, c/Compl/Comorb 82Neoplasias respiratórias 85Derrame pleural, com Complicações e/ou Comorbilidades 88Doença Pulmonar Crónica Obstructiva 89Pneumonia e pleurisia simples, Idade > 17 anos, com Complic./Comorbil. 92Doença pulmonar intersticial, com Complicações e/ou Comorbilidades 94Pneumotórax, com Complicações e/ou Comorbilidades 95Pneumotórax, sem Complicações e/ou Comorbilidades 99Sintomas e sinais respiratórios, com Complicações e/ou Comorbilidades 101Outros diagnósticos aparelho respiratório, com Complicações/Comorbilid 475Diagnósticos do aparelho respiratório com ventilação Graph 2 – Comparison between the two groups Table 5 – Description of the GDH code from the selected diagnosis.

28. Results – Pneumology department Paper Based vs Electronic Based Clinical Records Graph 2 – Comparison between the two groups GDH codeBefore (%)After (%) 751,72,7 762,72,1 798,56,8 8237,226,7 852,02,1 8810,211,6 895,87,5 922,02,1 941,03,1 954,85,1 992,42,7 1012,45,8 4751,42,4 Others17,719,2 Table 7 – % of each diagnosis on both periods

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

30. Results – Pneumology department Paper Based vs Electronic Based Clinical Records Diagnosis:“Neoplasias Respiratórias”(GDH82) 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 com complicações” (GDH101).

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

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

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

34. Aknowledgments W e 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. Paper Based vs Electronic Based Clinical Records