The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems (original) (raw)
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British Journal of General Practice
Background: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. Aim: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. Design of study: Retrospective cohort study. Setting: Eighteen general practices in the Exeter Primary Care Trust. Method: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, dependi ng on which mediu m st ored the clinical information from consultations. Results: More consultations were recorded in hybrid systems (median in 2 years = 11,
The electronic patient record in primary care--regression or progression? A cross sectional study
BMJ, 2003
To determine whether paperless medical records contained less information than paper based medical records and whether that information was harder to retrieve. Design Cross sectional study with review of medical records and interviews with general practitioners. Setting 25 general practices in Trent region. Participants 53 British general practitioners (25 using paperless records and 28 using paper based records) who each provided records of 10 consultations. Main outcome measures Content of a sample of records and doctor recall of consultations for which paperless or paper based records had been made. Results Compared with paper based records, more paperless records were fully understandable (89.2% v 69.9%, P=0.0001) and fully legible (100% v 64.3%, P < 0.0001). Paperless records were significantly more likely to have at least one diagnosis recorded (48.2% v 33.2%, P=0.05), to record that advice had been given (23.7% vs 10.7%, P=0.017), and, when a referral had been made, were more likely to contain details of the specialty (77.4% v 59.5%, P=0.03). When a prescription had been issued, paperless records were more likely to specify the drug dose (86.6% v 66.2%, P=0.005). Paperless records contained significantly more words, abbreviations, and symbols (P < 0.01 for all). At doctor interview, there was no difference between the groups for the proportion of patients or consultations that could be recalled. Doctors using paperless records were able to recall more advice given to patients (38.6% v 26.8%, P=0.03). Conclusion We found no evidence to support our hypotheses that paperless records would be truncated and contain more local abbreviations; and that the absence of writing would decrease subsequent recall. Conversely we found that the paperless records compared favourably with manual records.
Primary Care Patient Records in the United Kingdom: Past, Present, and Future Research Priorities
JOURNAL OF MEDICAL INTERNET RESEARCH, 2018
This paper briefly outlines the history of the medical record and the factors contributing to the adoption of computerized records in primary care in the United Kingdom. It discusses how both paper-based and electronic health records have traditionally been used in the past and goes on to examine how enabling patients to access their own primary care record online is changing the form and function of the patient record. In addition, it looks at the evidence for the benefits of Web-based access and discusses some of the challenges faced in this transition. Finally, some suggestions are made regarding the future of the patient record and research questions that need to be addressed to help deepen our understanding of how they can be used more beneficially by both patients and clinicians.
2018
UNSTRUCTURED This paper briefly outlines the history of the medical record and the factors contributing to the adoption of computerized records in primary care in the United Kingdom. It discusses how both paper-based and electronic health records have traditionally been used in the past and goes on to examine how enabling patients to access their own primary care record online is changing the form and function of the patient record. In addition, it looks at the evidence for the benefits of Web-based access and discusses some of the challenges faced in this transition. Finally, some suggestions are made regarding the future of the patient record and research questions that need to be addressed to help deepen our understanding of how they can be used more beneficially by both patients and clinicians.
Does Feedback Improve the Quality of Computerized Medical Records in Primary Care?
Journal of the American Medical Informatics Association, 2002
Although the majority of NHS (National Health Service) general practitioners in the United Kingdom are now computerized 1 and the computer systems they use have can record structured data (Read Coded 2 ; see box on next page), high-quality coding of clinical data is not yet universal. 3-5 There are a number of reasons for this. Until recently, general practitioners were required to keep written as well as computerized medical records. 6 Using computers in primary care also results in longer consultations. 7,8 Despite these obstacles, an increasing amount of clinical data is now being recorded electronically. 9 Many recent NHS policy documents have promoted the use of computerized records. These include the NHS information strategy, 10 the National Service Frameworks, 11 and the NHS Plan. 12 The more recent "Building the Information Core" document, 13 from the NHS Information Policy Unit, provides the most up-to-date milestones. A key target is that half the primary care trusts will have implemented electronic patient records by 2004. To improve the usefulness and accuracy of these electronic records, primary care trusts will need to implement programs that improve data quality. Evaluation of such interventions is lacking, however. 14
American Journal of Medical Quality, 2011
The adoption of electronic medical records (EMRs) in ambulatory settings has been widely recommended. It is hoped that EMRs will improve care; however, little is known about the effect of EMR use on care quality in this setting. This study compares EMR versus paper medical record documentation of basic health history and preventive service indicators in 47 community-based practices. Differences in practice level documentation rates between EMR-and non EMR-using practices were examined using the Kruskal-Wallis non-parametric test and robust regression, adjusting for practice level covariates. Frequencies of documentation of health history and preventive service indicator items were similar in the two groups of practices. While EMRs provide the capacity for more robust record keeping, the community-based practices here are not using EMRs to their full capacity. EMR usage does not guarantee more systematic record keeping and thus may not lead to improved quality in the community practice setting.
Information systems and the electronic health record in primary health care
Informatics in Primary Care, 2007
The implementation of information systems into primary health care opened the possibilities of providing integrated and co-ordinated health care, improved in quality and focused on the healthcare user. The healthcare system, researchers, physicians, and patients have recognised the benefits offered by informatics, but also raised questions that have yet to be answered.