Ghosh Abhijeet, McCarthy Sandra, Halcomb Elizabeth
COORDINARE - South Eastern NSW PHN, North Wollongong, NSW, Australia.
Centre for Health Initiatives, University of Wollongong, Wollongong, NSW, Australia.
BMC Fam Pract. 2016 Apr 26;17:50. doi: 10.1186/s12875-016-0445-8.
Technological advances in clinical data capturing and storage systems have led to recent attempts at disease surveillance and region specific population health planning through regularly collected primary care administrative clinical data. However the accuracy and comprehensiveness of primary care health records remain questionable.
We aimed to explore the perceptions and experiences of general practice staff in maintaining accurate patient health data within clinical software used in primary care settings of regional NSW. Focus groups were conducted with general practitioners, practice nurses and practice administrative staff from 17 practices in the Illawarra-Shoalhaven region of the state of New South Wales (NSW) in Australia that had participated in the Sentinel Practices Data Sourcing (SPDS) project - a general practice based chronic disease surveillance and data quality improvement study. A total of 25 respondents that included 12 general practitioners (GPs) and 13 practice staff participated in the 6 focus groups. Focus groups were audio-recorded and transcribed verbatim. Thematic analysis of the data was undertaken.
Five key themes emerged from the data. Firstly, the theme of resourcing data management raised issues of time constraints, the lack of a dedicated data management role and the importance of multidisciplinary involvement, including a data champion. The need for incentives was identified as being important to motivate ongoing commitment to maintaining data quality. However, quality of software packages, including coding issues and software limitations and information technology skills were seen as key barriers. The final theme provided insight into the lessons learnt from the project and the increased awareness of the importance of data quality amongst practice staff.
The move towards electronic methods of maintaining general practice patient records offers significant potential benefits in terms of both patient care and monitoring of health status and health needs within the community. However, this study has reinforced the importance of human factors in the maintenance of such datasets. To achieve optimal benefits of electronic health and medical records for patient care and for population health planning purposes, it is extremely essential to address the barriers that clinicians and other staff face in maintaining complete and correct primary care patient electronic health and medical information.
临床数据采集和存储系统的技术进步促使人们近期尝试通过定期收集的基层医疗行政临床数据进行疾病监测和特定区域的人群健康规划。然而,基层医疗健康记录的准确性和全面性仍存在疑问。
我们旨在探讨新南威尔士州(NSW)地区基层医疗环境中使用的临床软件内,全科医疗工作人员在维护准确患者健康数据方面的看法和经验。对来自澳大利亚新南威尔士州伊拉瓦拉 - 肖尔黑文地区17家参与哨兵实践数据来源(SPDS)项目的诊所的全科医生、执业护士和诊所行政人员进行了焦点小组访谈。该项目是一项基于全科医疗的慢性病监测和数据质量改进研究。共有25名受访者参与了6个焦点小组,其中包括12名全科医生和13名诊所工作人员。焦点小组进行了录音并逐字转录。对数据进行了主题分析。
数据中出现了五个关键主题。首先,数据管理资源主题提出了时间限制问题、缺乏专门的数据管理角色以及多学科参与(包括数据倡导者)的重要性。激励措施的必要性被认为对持续致力于维护数据质量很重要。然而,软件包的质量,包括编码问题、软件限制和信息技术技能被视为关键障碍。最后一个主题深入探讨了从该项目中学到的经验教训以及诊所工作人员对数据质量重要性的认识提高。
转向电子方式维护全科医疗患者记录在患者护理以及社区内健康状况和健康需求监测方面具有显著的潜在益处。然而,本研究强化了人为因素在维护此类数据集方面的重要性。为了实现电子健康和医疗记录在患者护理和人群健康规划方面的最佳效益,解决临床医生和其他工作人员在维护完整和正确的基层医疗患者电子健康和医疗信息时面临的障碍极其重要。