Accuracy and completeness of electronic patient records in primary care

Abstract

Family practitioners and other staff working in primary care require comprehensive and accurate data on patients at the point-of-care if they are to provide high quality health services to their patients. Electronic patient records are an effective method of achieving this objective, by dispensing with the need to use difficult to access, and often illegible, paper-based records. Hence, the implementation of electronic patient records in primary care is a key objective of many health care systems, including both the USA and UK. This reflects a growing recognition of the potential benefits of electronic records on the safety, quality and efficiency of healthcare. Electronic patient records underpin many information technology initiatives in primary care, such as screening for identifying patients at high risk of cardiovascular disease, call–recall systems for asthma and other long-term disease management programmes, computerized decision support systems for prescribing, electronic ordering of tests and electronic referral systems to secondary care. These are all, however, dependant on comprehensive and accurate coded data. There are known to be large variations in the accuracy and completeness of the clinical information stored in electronic patient records. In a systematic review, Thiru et al. identified 52 studies that examined data quality in electronic primary care records. Quality of data was measured in different ways, most commonly by comparisons of rates derived from the electronic records with an external standard. Prescriptions had the highest rate of recording, probably because prescribing is a core function of many electronic patient record systems. The recording of diseases (i.e. diagnoses) varied, with completeness generally highest for diseases with clear diagnostic criteria. Lifestyle and socio-economic data had lower rates of recording than prescription or diagnostic data. In another systematic review, Jordan et al. identified 24 studies that examined morbidity coding in primary care. Recording of consultations was generally high (typically greater than 90%), but assigning a morbidity code during each consultation was more variable (66–99% complete). Coronary heart disease was the most commonly assessed disease register in previous studies and completeness of recording was generally moderate (typically around 70%). Positive predictive value of coronary heart disease registers was generally high (typically around 83–100%). Other diseases that were examined (such as asthma and epilepsy) showed similar patterns of completeness of recording and positive predictive value of recorded diagnoses, but rates were generally lower than for coronary heart disease. Two recent papers in Family Practice also look at the issues of recording and coding of data in primary care. Pascoe et al. identified major omissions in the cancer diagnoses held by five general practices in Leeds, UK. The recording of diagnoses in primary care was less complete and, when a diagnosis of cancer was recorded, it was generally less detailed than in the data held by the Regional Cancer Registry. Soler et al. describe the progress of the International Classification of Primary Care (ICPC) in the 21 years since its introduction. The classification, now endorsed by the World Health Organization, has been translated into 22 languages. The wide use of the ICPC facilitates international comparisons of clinical practice and coding in primary care. For the time being, however, the use of Read codes as the UK’s standard classification system in primary care makes comparisons with countries using ICPC difficult. One important conclusion of previous studies on the use of electronic patient records in primary care is that the completeness and accuracy of data entry relies mainly on the enthusiasm of family practitioners. There are currently no agreed reference standards for reporting data quality in primary care and this limits measurement of data quality in electronic patient records. Clinicians do understand the potential benefits from the use of electronic patient records in their practices, but also cite major barriers to their implementation. These include the capital cost of investment in information technology (this may be less of an issue in the UK where the capital costs are largely met by the NHS) and the workload implications. A second key area is the lack of standards that permit effective, accurate