Impact of the implementation of electronic health records on the quality of discharge summaries and on the coding of hospitalization episodes

Objective: To determine whether the implementation and use of the electronic health records (EHR) modifies the quality, readability and/or the length of the discharge summaries (DS) and the average number of coded diagnosis and procedures per hospitalization episode. Design: A pre-post-intervention descriptive study conducted between 2010 and 2014. Setting: The 'Hospital Universitario 12 de Octubre' (H12O) of Madrid (Spain). A tertiary University Hospital of up to 1200 beds. Intervention: Implementation and systematic use of the EHR. Main Outcome Measures: The quality, length and readability of the DS and the number of diagnosis and procedures codes by raw and risk-adjusted data. Results: A total of 200 DS were included in the present work. After the implementation of the EHR the DS had better quality per formal requirements, although were longer and harder to read (P < 0.001). The average number of coded diagnoses and procedures was increased, 9.48 in the PRE-INT and 10.77 in the POST-INT, and the difference was statistically significant (P < 0.001) in both raw and risk-adjusted data. Conclusions: The implementation of EHR improves the formal quality of DS, although poor use of EHR functionalities might reduce its understandability. Having more clinical information immediately available due to EHR increases the number of diagnosis and procedure codes enhancing their utility for secondary uses.