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Abstract
BackgroundImprovements in the quality of health care services are often measured using data present in medical records. Electronic Medical Records (EMRs) contain potentially valuable new sources of health data. However, data quality in EMRs may not be optimal and should be assessed. Data reliability (are the same data elements being measured over time?) is a prerequisite for data validity (are the data accurate?). Our objective was to measure the reliability of data for preventive services in primary care EMRs during the transition to EMR.MethodsOur data sources were randomly selected eligible patients’ medical records and data obtained from provincial administrative datasets. Eighteen community-based family physicians in Toronto, Ontario that implemented EMRs starting in 2006 participated in this study. We measured the proportion of patients eligible for a service (Pap smear, screening mammogram or influenza vaccination) that received the service. We compared the change in rates of selected preventive services calculated from the medical record audits with the change in administrative datasets.ResultsIn the first year of EMR use (2006) services decreased by 8.7% more (95% CI −11.0%– − 6.4%, p < 0.0001) when measured through medical record audits as compared with administrative datasets. Services increased by 2.4% more (95% CI 0%–4.9%, p = 0.05) in the medical record audits during the second year of EMR use (2007).ConclusionThere were differences between the change measured through medical record audits and administrative datasets. Problems could include difficulties with organizing new data entry processes as well as continued use of both paper and EMRs. Data extracted from EMRs had limited reliability during the initial phase of EMR implementation. Unreliable data interferes with the ability to measure and improve health care quality
Highlights
Improvements in the quality of health care services are often measured using data present in medical records
Data quality factors can be categorized as data completeness, data reliability and data validity [14,15]
We studied the change in preventive services in the two years prior to Electronic Medical Records (EMRs) implementation (2004 and 2005) and the first two years of EMR implementation (2006 and 2007)
Summary
Improvements in the quality of health care services are often measured using data present in medical records. Our objective was to measure the reliability of data for preventive services in primary care EMRs during the transition to EMR. The transition from paper-based records to Electronic Medical Records (EMRs) has led to expectations that electronic health care data can and will be used to measure and improve the quality of care provided to patients [2,3]. Data quality factors can be categorized as data completeness (are all the data present?), data reliability (are data recorded in the same way across practices and over time?) and data validity (are the data correct?) [14,15]. “there are no agreed reference standards for reporting data quality in primary care and this limits measurement of data quality in electronic patient records” [20]. While there are many possible ways to measure EMR data quality and many areas that can be measured, [8,21,22] systematic reviews of data quality assessment have noted a focus on diagnostic data, laboratory testing, risk factors and demographic information, with limited information on data quality regarding preventive services [7,15]
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