{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T11:53:23Z","timestamp":1784548403987,"version":"3.55.0"},"reference-count":55,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2025,3,10]],"date-time":"2025-03-10T00:00:00Z","timestamp":1741564800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"},{"start":{"date-parts":[[2025,3,10]],"date-time":"2025-03-10T00:00:00Z","timestamp":1741564800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Med Inform Decis Mak"],"DOI":"10.1186\/s12911-025-02949-1","type":"journal-article","created":{"date-parts":[[2025,3,10]],"date-time":"2025-03-10T11:37:26Z","timestamp":1741606646000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Analyzing the medical record homepages quality in a Chinese EMR system"],"prefix":"10.1186","volume":"25","author":[{"given":"Dandan","family":"Ge","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yong","family":"Xia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhonghua","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,3,10]]},"reference":[{"key":"2949_CR1","doi-asserted-by":"crossref","unstructured":"Atherton J. Development of the electronic health record. Virtual Mentor Vm. 2011;13(3).","DOI":"10.1001\/virtualmentor.2011.13.3.mhst1-1103"},{"issue":"3","key":"2949_CR2","first-page":"73","volume":"35","author":"A Walker","year":"2019","unstructured":"Walker A, Lake K, Rudokas M. Summary care record (SCR): impact on medicines reconciliation and patient care in a private healthcare hospital providing NHS services:a small-scale proof of concept stud. J Pharm Manage. 2019;35(3):73\u20137.","journal-title":"J Pharm Manage"},{"issue":"4","key":"2949_CR3","first-page":"332","volume":"29","author":"J Cantiello","year":"2010","unstructured":"Cantiello J, Cortelyou-Ward KH. The American recovery and reinvestment act: lessons learned from physicians who have gone electronic. J Pharm Manage. 2010;29(4):332\u20138.","journal-title":"J Pharm Manage"},{"issue":"3","key":"2949_CR4","doi-asserted-by":"publisher","first-page":"654","DOI":"10.1111\/1468-0009.12214","volume":"94","author":"M Gold","year":"2016","unstructured":"Gold M, Mclaughlin C. Assessing HITECH implementation and lessons: 5 years later. Milbank Q. 2016;94(3):654\u201387.","journal-title":"Milbank Q"},{"issue":"9","key":"2949_CR5","first-page":"980","volume":"54","author":"H Ishida","year":"2006","unstructured":"Ishida H, Inoue Y. Contributions of university hospitals to local health integration networks[J]. Rinsho Byori Japanese J Clin Pathol Rinsho Byori Japanese J Clin Pathol. 2006;54(9):980\u20136.","journal-title":"Rinsho Byori Japanese J Clin Pathol Rinsho Byori Japanese J Clin Pathol"},{"key":"2949_CR6","unstructured":"National Health Commision Of The Peopel\u2019S Republic Of China. Notice on printing and distributing the administrative measures for grading evaluation of application level of electronic medical record system (Trial) and evaluation standards (Trial)[EB\/OL]. In."},{"key":"2949_CR7","unstructured":"Shu Ting, Hua Z, Liu H. Analysis on the application level of hospital electronic medical record system in China in 2020. Chin Health Qual Manage. 2022(29):8\u201310."},{"key":"2949_CR8","unstructured":"National Health Commision Of The Peopel S Republic Of China. Notice on further promoting the informatization construction of medical institutions with electronic medical records as the core. In."},{"key":"2949_CR9","unstructured":"Xie Youmian Y, Fang X. Xuejun. Discussion on improving the quality of medical record front pages by electronic medical record system. Chin Med Records. 2020(21):40\u20132."},{"key":"2949_CR10","unstructured":"National Health Commision Of The Peopel\u2019S Republic Of China. Notice of the general office of the national health and family planning commission on issuing the quality standards for filling in the homepage page data of inpatient medical records (provisional) and the quality management and control indicators for the home page data of inpatient medical records. (2016 edition). In."},{"key":"2949_CR11","unstructured":"He Qifang. Analysis on the coding defects of abnormal cases included in gynecology department based on chs-drg. Chin Med Records. 2022(23):29\u201331."},{"key":"2949_CR12","unstructured":"Lin Baochun C, Bo Z. Bin. Analysis on the quality of the home page of inpatient medical records based on the performance appraisal of a tertiary public hospital. Chin Med Records. 2021(22):22\u20135."},{"key":"2949_CR13","doi-asserted-by":"crossref","unstructured":"Adams WG, Mann AM, Bauchner H. Use of an electronic medical record improves the quality of urban pediatric primary care. Pediatr Pediatr. 2003(111):626.","DOI":"10.1542\/peds.111.3.626"},{"key":"2949_CR14","doi-asserted-by":"crossref","unstructured":"Tiffany Luu L, Spiegelman D, Nykin K, Abido J, Roh S, Rudkin E. Al. Implementation of an electronic health record\u2013based messaging system in the emergency department: effects on physician workflow and resident burnout. J Patient Saf. 2022(18):pe542\u20136546.","DOI":"10.1097\/PTS.0000000000000869"},{"key":"2949_CR15","unstructured":"Xia Jian Y, Min L. Peng. Effect of setting time node in chest pain template of structured electronic medical record on emergency diagnosis and treatment of chest pain. Chongqing Med Sci. 2021(50):874\u20135."},{"key":"2949_CR16","doi-asserted-by":"crossref","unstructured":"Senishaw AF, Tilahun BC, Nigatu AM, Mengiste SA, Standal K. Willingness to use electronic medical record (emr) system and its associated factors among health professionals working in Amhara region private hospitals 2021, Ethiopia. PLoS ONE. 2023(18):e282044.","DOI":"10.1371\/journal.pone.0282044"},{"key":"2949_CR17","doi-asserted-by":"crossref","unstructured":"Boesch TS, Eischen E, Ries AM, Quinn A, Dave A, Beezhold DW. Promoting \u03b2-lactam utilization through suppression of electronic medical record cross-allergy alerts. Am J Health Syst Pharm. 2022(79):S43\u201352.","DOI":"10.1093\/ajhp\/zxac040"},{"key":"2949_CR18","doi-asserted-by":"crossref","unstructured":"Claus J, Fimmel MQ, Khan Y, Belopolsky P, Imas A, Gampa A, Sonnenberg. Sustained and cumulative impact of an electronic medical record-based alert on a hepatitis C birth cohort screening program. J Viral Hepat. 2021(28):1200\u20135.","DOI":"10.1111\/jvh.13524"},{"key":"2949_CR19","doi-asserted-by":"crossref","unstructured":"Shi M, Yang A, Lau ESH, Luk AOY, Ma RCW, Kong APS, Et Al. A novel electronic health record-based, machine-learning model to predict severe hypoglycemia leading to hospitalizations in older adults with diabetes: a territory-wide cohort and modeling study. Plos Med. 2024(21):e1004369.","DOI":"10.1371\/journal.pmed.1004369"},{"key":"2949_CR20","doi-asserted-by":"crossref","unstructured":"Iyer PG, Sachdeva K, Leggett CL, Codipilly DC, Abbas H, Anderson K, Et Al. Development of electronic health record-based machine learning models to predict barrett\u2019s esophagus and esophageal adenocarcinoma risk. Clin Transl Gastroen. 2023(14):e637.","DOI":"10.14309\/ctg.0000000000000637"},{"key":"2949_CR21","doi-asserted-by":"crossref","unstructured":"Qiao Pan C, Huang D, Chen. A method based on multi-standard active learning to recognize entities in electronic medical record. Math Biosci Eng. 2021(18):1000\u201321.","DOI":"10.3934\/mbe.2021054"},{"key":"2949_CR22","doi-asserted-by":"crossref","unstructured":"Mehta S, Grant K, Ackery A. Bmj Health Care Inform. (2020) 27:E100217. 2020(27):e100217.","DOI":"10.1136\/bmjhci-2020-100217"},{"key":"2949_CR23","unstructured":"Tapuria Archana P, Talya K, Dipak D, Glen X, Sun, Vasa C. Impact of patient access to their electronic health record: systematic review. Inf Health Soc Ca. 2021(46):11\u20133."},{"key":"2949_CR24","doi-asserted-by":"crossref","unstructured":"Usman M, U Q. Secure electronic medical records storage and sharing using blockchain technology. Procedia Comput Sci. 2020:321\u20137.","DOI":"10.1016\/j.procs.2020.06.093"},{"key":"2949_CR25","unstructured":"Li Wenqiang W, Huabing M, Xiali, Zhenhog L. Quality improvement of main diagnosis and main surgery filling in the front page of inpatient medical records. Chin Med Records. 2020(21):8\u201310."},{"key":"2949_CR26","doi-asserted-by":"crossref","unstructured":"Harris AM, Ziemba J, Bylund J. Implementing a root cause analysis program to enhance patient safety education in urology residency. Urology. 2020(138):24\u20139.","DOI":"10.1016\/j.urology.2019.11.059"},{"issue":"3","key":"2949_CR27","doi-asserted-by":"publisher","first-page":"337","DOI":"10.1515\/dx-2023-0161","volume":"11","author":"SV Phadke","year":"2024","unstructured":"Phadke SV, Dalal C, Seetharaman R, As P. Lessons in clinical reasoning - pitfalls, Myths, and pearls: a case of tarsal tunnel syndrome caused by an intraneural ganglion cyst. Diagnosis (Berl). 2024;11(3):337\u201342.","journal-title":"Diagnosis (Berl)"},{"key":"2949_CR28","unstructured":"Qu Fang D, Luqian H, Waiguang Z, Weijun S, Qianshang T, Wei. Quality analysis of homepage data of inpatient cases in 52 tertiary hospitals in a Province. Chin Med Records. 2019(20):22\u20135."},{"issue":"04","key":"2949_CR29","first-page":"14","volume":"25","author":"Li","year":"2024","unstructured":"Li, Li. Analysis and countermeasures on the defects of the first page of 1200 inpatient cases in a hospital. Chin Med Records. 2024;25(04):14\u20136.","journal-title":"Chin Med Records"},{"issue":"07","key":"2949_CR30","first-page":"21","volume":"24","author":"H Zhang","year":"2023","unstructured":"Zhang H. Analysis of the writing quality of the first page of 1183 inpatient cases in a hospital. China Med Records. 2023;24(07):21\u20134.","journal-title":"China Med Records"},{"issue":"5","key":"2949_CR31","first-page":"13","volume":"22","author":"S Wang Yong","year":"2021","unstructured":"Wang Yong S, Bingxing Y, Shiwei. A survey on the quality of the first page of 3261 surgical cases in a tertiary public hospital. China Med Records. 2021;22(5):13\u20136.","journal-title":"China Med Records"},{"issue":"01","key":"2949_CR32","first-page":"13","volume":"23","author":"Y Zhang","year":"2022","unstructured":"Zhang Y. Quality analysis of 7664 inpatient medical cases by filling in the first page. Chin Med Records. 2022;23(01):13\u20135.","journal-title":"Chin Med Records"},{"key":"2949_CR33","doi-asserted-by":"publisher","first-page":"688","DOI":"10.1186\/s12913-023-09686-z","volume":"23","author":"Q Li","year":"2023","unstructured":"Li Q, Fan X, Jian W. Impact of diagnosis-related-group (drg) payment on variation in hospitalization expenditure: evidence from China. Bmc Health Serv Res. 2023;23:688.","journal-title":"Bmc Health Serv Res"},{"key":"2949_CR34","doi-asserted-by":"crossref","unstructured":"Meng Z, Zou K, Song S, Wu H, Han Y. Associations of Chinese diagnosis-related group systems with inpatient expenditures for older people with hip fracture. Bmc Geriatr. 2022(22):169.","DOI":"10.1186\/s12877-022-02865-3"},{"key":"2949_CR35","doi-asserted-by":"crossref","unstructured":"Zhao C, Wang C, Shen C, Wang Q. Diagnosis-related group (drg)-based case-mix funding system, a promising alternative for fee for service payment in China. Biosci Trends. 2018(12):109\u201315.","DOI":"10.5582\/bst.2017.01289"},{"issue":"1","key":"2949_CR36","doi-asserted-by":"publisher","first-page":"264","DOI":"10.1186\/s12889-021-10295-w","volume":"21","author":"S Garies","year":"2021","unstructured":"Garies S, McBrien K, Quan H, Manca D, Drummond N, Williamson T. A data quality assessment to inform hypertension surveillance using primary care electronic medical record data from Alberta, Canada. BMC Public Health. 2021;21(1):264.","journal-title":"BMC Public Health"},{"issue":"6","key":"2949_CR37","doi-asserted-by":"publisher","first-page":"1107","DOI":"10.1093\/jamia\/ocw013","volume":"23","author":"A Singer","year":"2016","unstructured":"Singer A, Yakubovich S, Kroeker AL, Dufault B, Duarte R, Katz A. Data quality of electronic medical records in Manitoba: do problem lists accurately reflect chronic disease billing diagnoses? J Am Med Inf Assn. 2016;23(6):1107\u201312.","journal-title":"J Am Med Inf Assn"},{"issue":"9","key":"2949_CR38","doi-asserted-by":"publisher","first-page":"3750","DOI":"10.1111\/iwj.14270","volume":"20","author":"A P\u00f6yry","year":"2023","unstructured":"P\u00f6yry A, Kimpim\u00e4ki T, Kaartinen I, Salmi TT. Quality registry improves the data of chronic ulcers: validation of Tampere wound registry. Int Wound J. 2023;20(9):3750\u20139.","journal-title":"Int Wound J"},{"issue":"1","key":"2949_CR39","first-page":"19","volume":"49","author":"C Doktorchik","year":"2020","unstructured":"Doktorchik C, Lu M, Quan H, Ringham C, Eastwood C. A qualitative evaluation of clinically coded data quality from health information manager perspectives. Health Inf Manag J. 2020;49(1):19\u201327.","journal-title":"Health Inf Manag J"},{"issue":"4","key":"2949_CR40","first-page":"307","volume":"26","author":"Z Liang Jingxing","year":"2019","unstructured":"Liang Jingxing Z, Yong H, Yuewen W, Xiaolin H, Yanhong L, Mingkun Y, Hongjuan Y, Xiaomin W, Liling X, et al. Analysis of filling and coding deficiencies of diagnosis and surgical operation on the first page of cases based on high multiplicity cases under DRGs payment. China Hosp Stat. 2019;26(4):307\u201310.","journal-title":"China Hosp Stat"},{"issue":"5","key":"2949_CR41","doi-asserted-by":"publisher","first-page":"1666","DOI":"10.1002\/hpm.3254","volume":"36","author":"N Hosseini","year":"2021","unstructured":"Hosseini N, Kimiafar K, Mostafavi SM, Kiani B, Zendehdel K, Zareiyan A, Eslami S. Factors affecting the quality of diagnosis coding data with a triangulation view: A qualitative study. Int J Health Plan M. 2021;36(5):1666\u201384.","journal-title":"Int J Health Plan M"},{"issue":"06","key":"2949_CR42","doi-asserted-by":"publisher","first-page":"1107","DOI":"10.1093\/jamia\/ocw013","volume":"23","author":"A Singer","year":"2016","unstructured":"Singer A, Yakubovich S, Kroeker AL, Dufault B, Duarte R, Katz A. Data quality of electronic medical records in Manitoba: do problem lists accurately reflect chronic disease billing diagnoses? J Am Med Inf Assoc. 2016;23(06):1107\u201312.","journal-title":"J Am Med Inf Assoc"},{"issue":"01","key":"2949_CR43","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1186\/s12882-021-02301-5","volume":"22","author":"A Nimmo","year":"2021","unstructured":"Nimmo A, Steenkamp R, Ravanan R, Taylor D. Do routine hospital data accurately record comorbidity in advanced kidney disease populations? A record linkage cohort study. Bmc Nephrol. 2021;22(01):95.","journal-title":"Bmc Nephrol"},{"issue":"Suppl 1","key":"2949_CR44","doi-asserted-by":"publisher","first-page":"2988","DOI":"10.1111\/1475-6773.12819","volume":"53","author":"MB Laws","year":"2018","unstructured":"Laws MB, Michaud J, Shield R, McQuade W, Wilson IB. Comparison of electronic health Record-Based and Claims-Based diabetes care quality measures: causes of discrepancies. Health Serv Res. 2018;53(Suppl 1):2988\u20133006.","journal-title":"Health Serv Res"},{"issue":"14","key":"2949_CR45","first-page":"11","volume":"14","author":"H Yanfang","year":"2023","unstructured":"Yanfang H, Xiaofang Z, Chenyanmin W. Analysis of factors affecting the generation of ambiguous cases in the CHS-DRG subdivision group programme (version 1.1). China Health Standard Manage. 2023;14(14):11\u20135.","journal-title":"China Health Standard Manage"},{"key":"2949_CR46","unstructured":"Tingting L. Research on the current situation and influencing factors of the quality of filling in the first page of inpatient cases. Shandong University; 2022."},{"issue":"6","key":"2949_CR47","doi-asserted-by":"publisher","first-page":"1023","DOI":"10.1007\/s10096-019-03501-6","volume":"38","author":"X Gansel","year":"2019","unstructured":"Gansel X, Mary M, van Belkum A. Semantic data interoperability, digital medicine, and e-health in infectious disease management: a review. Eur J Clin Microbiol. 2019;38(6):1023\u201334.","journal-title":"Eur J Clin Microbiol"},{"issue":"4","key":"2949_CR48","first-page":"410","volume":"4","author":"H Wu","year":"2017","unstructured":"Wu H, LaRue EM. Linking the health data system in the U.S.: challenges to the benefits. Int J Nurs Sci. 2017;4(4):410\u20137.","journal-title":"Int J Nurs Sci"},{"issue":"3","key":"2949_CR49","first-page":"22","volume":"24","author":"A Edwards","year":"2010","unstructured":"Edwards A, Hollin I, Barry J, Kachnowski S. Barriers to cross\u2013institutional health information exchange: a literature review. J Healthc Inf Manag. 2010;24(3):22\u201334.","journal-title":"J Healthc Inf Manag"},{"issue":"1","key":"2949_CR50","doi-asserted-by":"publisher","first-page":"203","DOI":"10.1055\/s-0042-1742519","volume":"31","author":"IN Sarkar","year":"2022","unstructured":"Sarkar IN. Transforming health data to actionable information: recent progress and future opportunities in health information exchange. Yearb Med Inf. 2022;31(1):203\u201314.","journal-title":"Yearb Med Inf"},{"key":"2949_CR51","unstructured":"Liu Zeqing Z, Jin E. Analysis of the quality of filling in the first page of inpatient cases in a hospital. Chin Med Records. 22(10):10\u20131."},{"issue":"1","key":"2949_CR52","first-page":"35","volume":"38","author":"P Cheng","year":"2009","unstructured":"Cheng P, Gilchrist A, Robinson KM, Paul L. The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding. Health Inf Manag J. 2009;38(1):35\u201346.","journal-title":"Health Inf Manag J"},{"issue":"1","key":"2949_CR53","doi-asserted-by":"publisher","first-page":"101894","DOI":"10.1016\/j.jsps.2023.101894","volume":"32","author":"S Albagmi","year":"2024","unstructured":"Albagmi S, Shawaheen M, Asiri EM, Alqadeer TA. Assessment of clinical miscoding errors and potential financial their implications on healthcare management - A case of local hospital in Najran, Saudi Arabia. Saudi Pharm J. 2024;32(1):101894.","journal-title":"Saudi Pharm J"},{"issue":"5 Pt 2","key":"2949_CR54","doi-asserted-by":"publisher","first-page":"1620","DOI":"10.1111\/j.1475-6773.2005.00444.x","volume":"40","author":"KJ O\u2019Malley","year":"2005","unstructured":"O\u2019Malley KJ, Cook KF, Price MD, Wildes KR, Hurdle JF, Ashton CM. Measuring diagnoses: ICD code accuracy. Health Serv Res. 2005;40(5 Pt 2):1620\u201339.","journal-title":"Health Serv Res"},{"issue":"06","key":"2949_CR55","first-page":"32","volume":"42","author":"W Zhao Jiaqi","year":"2021","unstructured":"Zhao Jiaqi W, Xiaofeng F. Study on the quality of electronic medical records and countermeasures. J Med Inf. 2021;42(06):32\u20136.","journal-title":"J Med Inf"}],"container-title":["BMC Medical Informatics and Decision Making"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12911-025-02949-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12911-025-02949-1\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12911-025-02949-1.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,3,10]],"date-time":"2025-03-10T11:37:40Z","timestamp":1741606660000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmcmedinformdecismak.biomedcentral.com\/articles\/10.1186\/s12911-025-02949-1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,3,10]]},"references-count":55,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["2949"],"URL":"https:\/\/doi.org\/10.1186\/s12911-025-02949-1","relation":{},"ISSN":["1472-6947"],"issn-type":[{"value":"1472-6947","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,3,10]]},"assertion":[{"value":"18 June 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"24 February 2025","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"10 March 2025","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This study was conducted according to the ethical guidelines of the Helsinki Declaration and was approved by the Ethics Committee of the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital). The Ethics Committee of the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital) exempted informed consent because of the retrospective nature of this research. Prior to the analysis, the names of patients and other key information for personal identification were anonymized and de-identified.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"121"}}