Tilyard M W, Munro N, Walker S A, Dovey S M
Department of General Practice, Dunedin School of Medicine.
N Z Med J. 1998 Aug 28;111(1072):317-8, 320.
To assess the feasibility of implementing the recommendations of the New Zealand National Minimum Data Set working party in computerised general practices.
Doctors from 12 computerised general practices belonging to the Royal New Zealand College of General Practitioners' Dunedin Research Unit Computer Network participated in the study (five Dunedin practices, four in rural Otago and Southland, and three in Christchurch). A three-month sample of data was extracted from practice computers and evaluated for completeness and compliance to the national minimum data set structure. Rates of recording practice identifier, provider, patient identifiers, sex, ethnicity, government subsidy eligibility, consultation identifier and date, prescriptions and Read codes were calculated for each practice.
Apart from data recorded automatically by computers, there was a wide range in the extent of missing data. Of the data requiring manual computer entry, patient demography and subsidy eligibility were most comprehensively recorded (date of birth 99.9%, sex 99.6%, eligibility to subsidies 98.5%). Data with little immediate clinical or management relevance were poorly recorded (Read codes 32.4% and ethnicity 5.0%).
It is possible to derive a common minimum data set from different computerised general practices. However some data elements will be missing unless suitable education and support are provided for the doctors and other staff members who record patient information.
评估在计算机化的全科医疗中实施新西兰国家最低数据集工作组建议的可行性。
来自新西兰皇家全科医师学院达尼丁研究单位计算机网络的12家计算机化全科医疗诊所的医生参与了该研究（5家达尼丁诊所，4家位于奥塔哥和南地农村地区，3家位于克赖斯特彻奇）。从诊所计算机中提取了三个月的数据样本，并评估其完整性以及是否符合国家最低数据集结构。计算每家诊所记录诊所标识符、提供者、患者标识符、性别、种族、政府补贴资格、会诊标识符和日期、处方及Read编码的比例。
除计算机自动记录的数据外，缺失数据的程度差异很大。在需要人工录入计算机的数据中，患者人口统计学信息和补贴资格记录最为全面（出生日期99.9%，性别99.6%，补贴资格98.5%）。与临床或管理直接相关性较小的数据记录较差（Read编码32.4%，种族5.0%）。
有可能从不同的计算机化全科医疗中得出一个通用的最低数据集。然而，除非为记录患者信息的医生和其他工作人员提供适当的教育和支持，否则某些数据元素将会缺失。
