Abstract
Primary health care electronic medical records were analyzedin Rio de Janeiro for two chronic diseases, namely, hypertension and diabetes, in a population-based study with a cross-sectional epidemiological design that considered the Rio de Janeiro population enrolled in Family Health Teams. Calculation of the prevalence rate was stratified by gender and age group, and the condition of the disease was measured by family doctors in their visits using the ICD-10.Except for the last two age groups (75-79 years and 80 years and over), with apparent under-registration of the diagnosed cases, a positive association was found between prevalence rates and age in both genders. The generation of objective and reliable statistical information is fundamental for local management, allowing the evaluation of demographic dynamics and the peculiarities of each territory, and assisting in the planning and monitoring of the quality of Rio de Janeiro people's records registered in each family health unit. Thus, the regular management of duplicate records in the registered user roster is essential to minimize the over-registration of clinical cases reported in the electronic medical records.
Highlights
Health information technology – the hardware, software, and infrastructure needed to collect, store, and exchange patient information in clinical practice has been changing healthcare in the world[1]
Some authors[10] point out that these records are a broad, low-cost data source, which allows longitudinal comparisons, cohort studies, quality assessment, and clinical trials with large sample sizes[11], which can be used for health surveillance, for chronic diseases such as diabetes, hypertension, and cardiovascular diseases, contributing in no small part to the morbimortality of the Brazilian population[12,13]
We considered electronic health records to describe a set of integrated, interoperable and customizable modules in the daily care of primary health care services[16], covering administrative, registration and clinical bases, with individual actions and group activities, procedures, medical consultations with records as per the International Classification of Diseases (ICD10), International Classification of Primary Care (ICPC), immunization, home visits, laboratory and exam results, medication and problem lists, accessed by all team professionals that are part of the services
Summary
Health information technology – the hardware, software, and infrastructure needed to collect, store, and exchange patient information in clinical practice has been changing healthcare in the world[1]. We considered electronic health records to describe a set of integrated, interoperable and customizable modules in the daily care of primary health care services[16], covering administrative, registration and clinical bases, with individual actions and group activities, procedures, medical consultations with records as per the International Classification of Diseases (ICD10), International Classification of Primary Care (ICPC), immunization, home visits, laboratory and exam results, medication and problem lists, accessed by all team professionals that are part of the services. Geographically-wise, a country’s postal code[17] and Census data can be used to obtain additional information on social determinants in health, including for academic research[18]
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