Informatics 99jun4

Journal of Informatics in Primary Care 1999 (June):13-14


Articles


The Clinical Content of the Computerised British General Practice Record

Dr Adrian A Pierry

The Surgery, 31 Cardiff Road, Llandaff, CARDIFF, CF5 2DP
email pierry@aol.com


Abstract

Evidence of a computerised record was found in about half of the 100 general practitioner record folders received from the Health Authority for newly-registered patients. Half of the computer records had some clinical data but no diagnostic entries, and of those with diagnostic entries only half contained free text notes. There was inconsistent data entry of important information.


Introduction

The information existant about the use of computer records in general practice is based mainly on the responses given by users to questionnaires, but information based on objective observation could prove more useful for planners.


Methods

The contents of 100 consecutive record folders of newly-registered patients received from the Health Authority between November 1997 and March 1998 were scrutinised by the author for the presence of any printout of a computer record. A second, independent, search was made by the practice manager, who photocopied all printouts of computer records she found. The information contained in the printouts was categorised using simple criteria and entered into a database. The results were analysed electronically.


Results

The 100 records included 53 females and 47 males aged 5 to 86 years old; only two were under 15 years old.

In 50 of the 100 folders, no computer record printout was found. In 4, the printout only had administrative information.

1 Clinical Information Found

Clinical information was found in 46 printouts of computer records, categorised as follows:

Category: Data on: No. of printouts where data present
Results of registration examination height 10
weight 22
exercise 10
alcohol 15
smoking 13
diet 6
urine test 9
blood pressure 23
allergies 12
family history 14
prescribing repeat 17
acute 13
contraception   8
cervical cytology   10
immunisations   24
referrals   5
investigations   12
number of records containing only information in categories above   24
diagnosis no free text 11
with free text 13
Read Codes explicit   6
number of records containing diagnostic entries also   24

NB: Items which were found less frequently were omitted.

Diagnostic entries unaccompanied by free text were very brief: of 100 such entries analysed, 33 consisted of a single word, 26 of two words, 23 of three words, and 18 had 4–5-worded entries.

2 Structuring of Information

The general structure found among the diversity of general practice computer systems used included:

  1. an unstructured list of sundry dated entries under headings including Journal, Analysis, Consultations, Activity, All entries.
  2. categorised information: these usually duplicated some of the above headings, but grouped according to:
  1. type of information, including the sort of categories in the table, and
  2. importance of the information, such information being highlighted by different systems as Active or Dormant problem, Acute or Chronic disease, Summary, Tagged diagnosis. A categorisation according to importance had been attempted in only 10 records, and in every one of them some trivial diagnosis or obviously unimportant investigation or referral had been included.

Further structuring was rare. Six records using the same system contained display of data in tabular form for dated entries of blood pressure, weight and height. A highly structured way of entering information on acute consultations was found in four records, using another system.


Conclusion

This study of medical records generated by the usage of a variety of general practice computer systems demonstrated that all these systems are being used in practices to record clinical and administrative information. The recording of diagnosis was picked up from a Read Code list, whether explicit or not. Data were grouped in practical, simple categories, with further structuring being exceptional and inconsistent. The level of usage of computer records appears to be low.


Editor’s Comments:

There are some limitations to this small ad hoc study, primarily:

  • not all practices choose to print out the computer record when the patient’s record is returned to the Health Authority, and there is no obligation to do so
  • most general practice clinical systems do not include every entry ever made in the printout, but provide a summary of what are felt to be the most significant data items; these printouts may or may not be configurable by the user
  • 100 sets of notes is a small sample for this sort of exercise
  • there are, since the advent of MIQUEST (see Meal's paper in this issue),easier ways of identifying what data are recorded in GP systems; the CHDGP project has found higher (and rising) levels of completeness, accuracy and consistency in recording on computer, albeit in volunteer practices rather than a sample of new patients’ records

It will also be interesting to see what effect the TextBase project has on improving the quality of recording in general practice computer systems, once records are electronically transferred to the new practice.

Refbacks

  • There are currently no refbacks.


This is an open access journal, which means that all content is freely available without charge to the user or their institution. Users are allowed to read, download, copy, distribute, print, search, or link to the full texts of the articles in this journal starting from Volume 21 without asking prior permission from the publisher or the author. This is in accordance with the BOAI definition of open accessFor permission regarding papers published in previous volumes, please contact us.

Privacy statement: The names and email addresses entered in this journal site will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party.

Online ISSN 2058-4563 - Print ISSN 2058-4555. Published by BCS, The Chartered Institute for IT