The Impact of Electronic Health Records Systems (EHRs) on the quality of clinical documentation

Abstract

Background: The frequent occurrence of medical errors threatens the quality of healthcare in Saudi Arabia (KSA). Although electronic health record (EHR) systems can help to minimize such errors by improving the quality of clinical documentation, there is low EHR adoption in KSA. There is insufficient evidence available in KSA to enhance understanding of EHRs’ benefits for healthcare quality. Aim: This study aims to provide evidence that EHR can improve healthcare quality in KSA by measuring its impact on the quality of clinical data. Method: This study was conducted at a Hospital in Madinah, KSA. It followed a quantitative methodology and a quasi-experimental design and depended on a sample of 578 records, which included 289 paper and 289 electronic records. Data were collected using the CRABEL (CRAwford-BEresford-Lafferty) score, a tool named after its creators, which is used to measure medical record quality in four elements of documentation: “initial clerking”, “subsequent entries”, “consent” and “discharge summary”. The CRABEL scores overall were recorded out of 100 for both paper and electronic records to evaluate the impact of EHR. The Statistical Package for the Social Sciences (SPSS), version 25 was adopted to analysing the study's data. Result: The overall quality of clinical documentation improved significantly after EHR adoption from 63.94% (63.49-64.42 95% confidence interval (CI)) to 90.39% (90.11-90.65, 95% CI) (t-test P = 0.001). The differences were also detected significantly in all categories of CRABEL score between pre- and post-EHR adoption. Conclusion: EHRs improve clinical documentation quality and should be adopted in clinical practice.