J Am Med Inform Assoc - Is the quality of data in an electronic medical record sufficient for assessing the quality of primary care?


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JECTIVE: Quality indicators for the treatment of type 2 diabetes are often retrieved from a chronic disease registry (CDR). This study investigates the quality of recording in a general practitioner's (GP) electronic medical record (EMR) compared to a simple, web-based CDR.METHODS: The GPs entered data directly in the CDR and in their own EMR during the study period (2011). We extracted data from 58 general practices (8235 patients) with type 2 diabetes and compared the occurrence and value of seven process indicators and 12 outcome indicators in both systems. The CDR, specifically designed for monitoring type 2 diabetes and reporting to health insurers, was used as the reference standard. For process indicators we examined the presence or absence of recordings on the patient level in both systems, for outcome indicators we examined the number of compliant or non-compliant values of recordings present in both systems. The diagnostic OR (DOR) was calculated for all indicators.RESULTS: We found less concordance for process indicators than for outcome indicators. HbA1c testing was the process indicator with the highest DOR. Blood pressure measurement, urine albumin test, BMI recorded and eye assessment showed low DOR. For outcome indicators, the highest DOR was creatinine clearance <30 mL/min or mL/min/1.73 m(2) and the lowest DOR was systolic blood pressure <140 mm Hg.CONCLUSIONS: Clinical items are not always adequately recorded in an EMR for retrieving indicators, but there is good concordance for the values of these items. If the quality of recording improves, indicators can be reported from the EMR, which will reduce the workload of GPs and enable GPs to maintain a good patient overview.

Resumo Limpo

jectiv qualiti indic treatment type diabet often retriev chronic diseas registri cdr studi investig qualiti record general practition gp electron medic record emr compar simpl webbas cdrmethod gps enter data direct cdr emr studi period extract data general practic patient type diabet compar occurr valu seven process indic outcom indic system cdr specif design monitor type diabet report health insur use refer standard process indic examin presenc absenc record patient level system outcom indic examin number compliant noncompli valu record present system diagnost dor calcul indicatorsresult found less concord process indic outcom indic hbac test process indic highest dor blood pressur measur urin albumin test bmi record eye assess show low dor outcom indic highest dor creatinin clearanc mlmin mlmin m lowest dor systol blood pressur mm hgconclus clinic item alway adequ record emr retriev indic good concord valu item qualiti record improv indic can report emr will reduc workload gps enabl gps maintain good patient overview

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