Availability and accuracy of electronic patient data for medical practice assessment.

UNLABELLED

We analyzed availability and accuracy of electronic patient data needed to assess medical practice. A case study was performed in which pediatricians formulated 14 performance indicators that cover aspects of care for children with suspected meningitis. Data items needed to quantify these indicators were listed. Required patient data were gathered from hospital information system and paper medical records. Accuracy of electronically available data was based on comparison with paper data and, when paper data were not available, on how data were recorded at the source, administrative procedures and original goal for which data were recorded.

CONCLUSION

Registration of reason for admission and diagnoses gives no reliable basis to select patients with 'suspicion on a disease' as selection criterion. Besides, many performance indicators cannot be reliably quantified because data are not recorded electronically (indication, medication, outpatient diagnosis), are not recorded specific enough (intervention time), are not standardized (radiology report), or cannot be obtained from other hospitals.