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 Participants and Methods 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) 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. Inclusion criteria 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 Methods – 1st Period First Period 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

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. Methods – 2 nd Period Paper Based vs Electronic Based Clinical Records Second Period 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: 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

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

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

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

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

20. 1 st Period Paper Based vs Electronic Based Clinical Records 1 st Period

21. 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.

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

23. 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

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

25. 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).

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

27. 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.

28. 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.

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

30. 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

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

32. 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).

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

34. 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.

35. 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.

36. 2 nd Period Paper Based vs Electronic Based Clinical Records 2 nd Period

37. Results - Obstetrics department Paper Based vs Electronic Based Clinical Records General (differences were found) Pearson Chi-Square 126,435( a) 15,000 Likelihood Ratio 134,71215,000 Linear-by-Linear Association 9,7051,002 N of Valid Cases 4728 Valuedf Asymp. Sig. (2-sided) a 0 cells (,0%) have expected count less than 5. The minimum expected count is 24,56. Diagnosis - Obstetrics

38. Results - Obstetrics department Paper Based vs Electronic Based Clinical Records Diagnosis - Obstetrics Diagnosis where differences were found V25.2 - Request for sterillization 654.21 - Previous cesarean section 664.01 – First-degree perineal laceration 661.11 - Secondary uterine inertia 648.21 - Anemia 656.11 - Rhesus isoimmunization

39. Results - Obstetrics department Paper Based vs Electronic Based Clinical Records Procedures - Obstetrics General (differences were found) Pearson Chi-Square 532,269( a) 15,000 Likelihood Ratio 584,29115,000 Linear-by-Linear Association 37,7841,000 N of Valid Cases 8136 Valuedf Asymp. Sig. (2-sided) 0 cells (,0%) have expected count less than 5. The minimum expected count is 58,69.

40. Results - Obstetrics department Paper Based vs Electronic Based Clinical Records Procedures - Obstetrics Procedures where differences were found 75.35 - Other diagnostic procedures on fetus and amnion 99.18 - Injection or infusion of electrolytes 73.59 - Other manually assisted delivery 90.59 - Microscopic examination of blood 88.78 - Diagnostic ultrasound of gravis uterus 73.6 - Episiotomy 75.34 -Fetal monitoring, not otherwise specified 99.29 - Injection or infusion of other therapeutic or prophylactic substance 72.71 -Vacuum extraction with episiotomy 93.57 - Aplication of other wound dressing

41. Results - Pneumology department Paper Based vs Electronic Based Clinical Records General (differences were found) Diagnosis - Pneumology Pearson Chi-Square 26,081(a)15,037 Likelihood Ratio 26,15815,036 Linear-by-Linear Association 2,5511,110 N of Valid Cases 4564 Valuedf Asymp. Sig. (2-sided) a 0 cells (,0%) have expected count less than 5. The minimum expected count is 24,67.

42. Results - Pneumology department Paper Based vs Electronic Based Clinical Records Diagnosis - Pneumology Diagnosis where differences were found Doenças do aparelho respiratório, NCOP - 519.8 Derrame pleural não especificado - 511.9 Pneumonia devida a microrganismo não especificado - 486

43. Results - Pneumology department Paper Based vs Electronic Based Clinical Records Procedures - Pneumology General (differences were found) Pearson Chi-Square 23,089(a)15,082 Likelihood Ratio 23,15715,081 Linear-by-Linear Association 1,1811,277 N of Valid Cases 5235 Valuedf Asymp. Sig. (2-sided) a 0 cells (,0%) have expected count less than 5. The minimum expected count is 44,60.

44. Results - Pneumology department Paper Based vs Electronic Based Clinical Records Procedures - Pneumology Procedures where differences were found Injecção ou infusão de electrolitos - 99.18

45. Diagnosis where differences were found Admissão para esterilização - V25.2 História de parto por cesariana, parto referenciado, c/ ou s/ condição anteparto - 654.21 Laceração períneo do primeiro grau - 664.01 Inércia uterina secundária - 661.11 Anemia complicando um parto referenciado, com ou sem menção de condição anteparto - 648.21 Isoimunização Rh condição anteparto com parto referenciado - 656.11 Discussion - Obstetrics department Paper Based vs Electronic Based Clinical Records Diagnosis - Obstetrics The increase in the number of cases, may possibly be justified by the attempt to reduce the practise of episiotomy.

46. Discussion - Obstetrics department Paper Based vs Electronic Based Clinical Records Procedures - Obstetrics Procedures where differences were found Actos de diagnóstico no feto e âmnio NCOP - 75.35 Parto manual assistido, não classificável em outra parte - 73.59 Exame microscópico NCOP do sangue - 90.59 Ultra - 88.78 Episiotomia - 73.6 Monitorização fetal NCOP - 75.34 (*) Extracção por ventosa com episiotomia - 72.71 Injecção ou infusão de electrolitos - 99.18 Injecção ou infusão de substancia terapêutica - 99.29 Aplicação de outros pensos para feridas - 93.57 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. it increased because it became indispensable in every case of non tranquilizer fetal state. 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. 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.

47. Discussion - Pneumology department Paper Based vs Electronic Based Clinical Records Diagnosis - Pneumology Diagnosis where differences were found Doenças do aparelho respiratório, NCOP - 519.8 Derrame pleural não especificado - 511.9 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.

48. Discussion – Pneumology department Paper Based vs Electronic Based Clinical Records Procedures - Pneumology Procedures where differences were found 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.

49. Diagnosis/ProceduresCodeIncrease/ Decrease% Diagnosis Obstetrics Request for sterillizationV25.2Decrease-64,29% Previous cesarean section654.21Decrease-48,28% First-degree perineal laceration664.01Increase 84,6 2% Secondary uterine inertia661.11Decrease-88,89% Anemia648.21Decrease-50,00% Rhesus isoimmunization656.11Increase14,06% Procedures Obstetrics Other diagnostic procedures on fetus and amnion 75.35Increase 48,1 9% Other manually assisted delivery73.59Increase43,06% Microscopic examination of blood90.59Increase 35,5 9% Diagnostic ultrasound of gravis uterus88.78Increase42,31% Episiotomy73.6Increase 25,4 2% Fetal monitoring, not otherwise specified 75.34Increase21,43% Vacuum extraction with episiotomy 72.71Increase37,93% Injection or infusion of electrolytes 99.18Decrease-73,68% Injection or infusion of other therapeutic or prophylactic substance 99.29Decrease-53,62% Aplication of other wound dressing93.57Decrease - 96,43 % Diagnosis Pneumology Other diseases of respiratory system, not elsewhere classified519.8Increase 47,3 7% Unspecified pleural effusion511.9Increase55,56% Pneumonia, organism unspecified486Increase88,89% Procedures Pneumology Injection or infusion of electrolytes99.18Decrease-34,29%

50. 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. Paper Based vs Electronic Based Clinical Records