How Accurate and Complete are the Contents of General Practitioners' Electronic Medical Record System? 2000

The background for "How Accurate and Complete are the Contents of General Practitioners' Electronic Medical Record System?, 2000" was the improvement potential the data material in electronic pasient journals (EPJs) had, in addition to research on epidemiology and further societal medicine. It was necessary to know more about the extents of the EPJ data, and how this data material could be compiled with what all involved agents knew about the patient. Therefore the project had several objectives: 1) To evaluate the completeness of the data material in EPJs. Was any data missing? 2) Evaluate the correctness of the data material in EPJs. Was the data correct? 3) Describe variations concerning eight frequent diagnosis, between medical offices. 4) Evaluate the practitioner's satisfaction with our feedback and software.

We could by the use of a program called QTools extract fields from EPJs. To find out how extensive the EPJ was, we counted blank fields. To retrieve information concerning correctness, we used several methods. For example we tied together different EPJ fields, for example diagnosis and medication, to identify each patient with a particular medical condition. Short informal interviews with practitioners and employees gave us more information concerning the data of the practices. The data material in practitioners' EPJs were very extensive, except for some fields (for example smoking, habits and field of work), but to interpret the correctness, a great caution was needed. A large part of the EPJs could be used for quality improvement and research, but one would then have to analyze the data material in close cooperation with the practices.