A structured registration program can be validly used for quality assessment in general practice

Andrea S Fokkens,P Auke Wiegersma,Sijmen A Reijneveld

doi:10.1186/1472-6963-9-241

Andrea S Fokkens, P Auke Wiegersma + Show 1 more

Open Access

https://doi.org/10.1186/1472-6963-9-241

Copy DOI

Abstract

BackgroundPatient information, medical history, clinical outcomes and demographic information, can be registered in different ways in registration programs. For evaluation of diabetes care, data can easily be extracted from a structured registration program (SRP). The usability of data from this source depends on the agreement of this data with that of the usual data registration in the electronic medical record (EMR).Aim of the study was to determine the comparability of data from an EMR and from an SRP, to determine whether the use of SRP data for quality assessment is justified in general practice.MethodsWe obtained 196 records of diabetes mellitus patients in a sample of general practices in the Netherlands. We compared the agreement between the two programs in terms of laboratory and non-laboratory parameters. Agreement was determined by defining accordance between the programs in absent and present registrations, accordance between values of registrations, and whether the differences found in values were also a clinically relevant difference.ResultsNo differences were found in the occurrence of registration (absent/present) in the SRP and EMR for all the laboratory parameters. Smoking behaviour, weight and eye examination were registered significantly more often in the SRP than in the EMR. In the EMR, blood pressure was registered significantly more often than in the SRP. Data registered in the EMR and in the SRP had a similar clinical meaning for all parameters (laboratory and non-laboratory).ConclusionsLaboratory parameters showed good agreement and non-laboratory acceptable agreement of the SRP with the EMR. Data from a structured registration program can be used validly for research purposes and quality assessment in general practice.

Highlights

Patient information, medical history, clinical outcomes and demographic information, can be registered in different ways in registration programs
No differences were found in the occurrence of registration in the structured registration program (SRP) and electronic medical record (EMR) for all the laboratory parameters
Data registered in the EMR and in the SRP had a similar clinical meaning for all parameters

Summary

Introduction

Medical history, clinical outcomes and demographic information, can be registered in different ways in registration programs. In an EMR data about a patient's medical history, clinical outcomes and demographic information is recorded. It can provide information about guidelines, patient condition, clinical outcomes and treatment [6]. These benefits from the EMR could result in more efficient and better patient care and care management [7,8]. Because clinical consultation is a complex interaction between caregiver and patient, in EMRs the information is often recorded as a mixture of free-text and coded data [15]. EMRs have not been designed to facilitate data retrieval [5]

Methods

Results

Discussion

Conclusion