Journal of the American Medical Informatics Association : JAMIA
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J Am Med Inform Assoc · Sep 2003
Comparative StudyComparing paper-based with electronic patient records: lessons learned during a study on diagnosis and procedure codes.
Paper-based and electronic patient records generally are used in parallel to support different tasks. Many studies comparing their quality do not report sufficiently on the methods used. Few studies refer to the patient. ⋯ The lessons learned from this study are that medical professionals should be cognizant of the possible discrepancies between paper and electronic information and look toward combining information from both records whenever appropriate. The inadequate methodology (transformations done by a single individual) used in the authors' study is typical of other studies in the field. The limited generalizability and restricted reproducibility of this commonly used approach emphasize the need to improve methods for comparing paper-based with electronic versions of a patient's chart.