Pringle M, Ward P, Chilvers C
Department of General Practice, Nottingham University Medical School.
Br J Gen Pract. 1995 Oct;45(399):537-41.
General practice computer databases are being increasingly seen as a source of data for public health monitoring and commissioning. Such ambitions depend on routine clinical data being recorded with acceptable completeness and accuracy.
The aim of this study was to assess the completeness and accuracy of the computer medical records in four high-recording general practices.
Four general practices in the Trent Region that use the EMIS computer system, and were known to be high recorders of clinical data on their computer databases, were selected. A retrospective analysis of the computer records, a prospective comparison of a sample of computer records with manual records, and a prospective comparison between videorecorded consultations and their manual and computer records were undertaken.
Checks for completeness in computer recording of diabetes mellitus and glaucoma showed high levels of accurate recording, 97% and 92% respectively. Prevalence rates between practices were reasonably comparable. No practice consistently, across 10 diagnoses, recorded prevalences higher or lower than the other practices; those diagnoses with recognized objective diagnostic criteria were recorded with a more consistent prevalence than those without. Lifestyle data recording was low; overall, smoking habits and alcohol consumption were recorded for 52% and 38% of patients aged over 16 years, respectively. Comparison of the manual records with the computer records showed that the computer records were sufficiently complete with regard to diagnoses (82% of all items recorded), prescriptions (100%) and referrals (67%), but missed most of the remaining data that a manual record captured. The videorecorded validation study showed that there were no important lapses in the recording of diagnoses, prescriptions or referrals when the computer recording was compared to the actual process of the consultations.
In these four high-recording practices the data in computer records were of sufficient completeness and accuracy to allow meaningful data aggregation for some diagnoses, prescriptions and referrals. Standardized protocols for defining which patients are included and excluded from major disease groups are required.
全科医疗计算机数据库越来越被视为公共卫生监测和医疗服务委托的数据来源。此类目标依赖于以可接受的完整性和准确性记录常规临床数据。
本研究旨在评估四家高记录量全科医疗诊所计算机病历的完整性和准确性。
选取特伦特地区使用EMIS计算机系统且已知在其计算机数据库中临床数据记录量高的四家全科医疗诊所。对计算机记录进行回顾性分析，对计算机记录样本与手工记录进行前瞻性比较，并对视频记录的会诊与其手工和计算机记录进行前瞻性比较。
对糖尿病和青光眼计算机记录完整性的检查显示准确记录水平较高，分别为97%和92%。各诊所之间的患病率相当可比。在10种诊断中，没有一家诊所始终记录的患病率高于或低于其他诊所；具有公认客观诊断标准的诊断记录的患病率比没有这些标准的诊断更一致。生活方式数据记录较少；总体而言，16岁以上患者中分别有52%和38%的吸烟习惯和饮酒情况被记录。将手工记录与计算机记录进行比较表明，计算机记录在诊断（记录了所有项目的82%）、处方（100%）和转诊（67%）方面足够完整，但遗漏了手工记录所捕获的大部分其余数据。视频记录验证研究表明，将计算机记录与会诊的实际过程进行比较时，在诊断、处方或转诊记录方面没有重大疏漏。
在这四家高记录量诊所中，计算机记录中的数据在完整性和准确性方面足以对某些诊断、处方和转诊进行有意义的数据汇总。需要制定标准化方案来确定哪些患者纳入或排除在主要疾病组之外。
