ASSESSMENT OF THE COMPLETENESS AND ACCURACY OF COMPUTER MEDICAL RECORDS IN 4 PRACTICES COMMITTED TO RECORDING DATA ON COMPUTER

Background. General practice computer databases are being increasingly seen as a source of data for public health monitoring and commissioni ng. Such ambitions depend on routine clinical data being recorded with acceptable completeness and accuracy. Aim. The aim of this study was to assess the completeness and accuracy of the computer medical record s in four high-recording general practices. Method Four general practi ces in the Trent Region that use the EMIS computer system, and were kn own to be high recorders of clinical data on their computer databases, were selected. A retrospective analysis of the computer records, a pr ospective comparison of a sample of computer records with manual recor ds, and a prospective comparison between videorecorded consultations a nd their manual and computer records were undertaken. Results. Checks for completeness in computer recording of diabetes mellitus and glauco ma showed high levels of accurate recording, 97% and 92% respectively. Prevalence rates between practices were reasonably comparable. No pra ctice consistently, across 10 diagnoses, recorded prevalences higher o r lower than the other practices; those diagnoses with recognized obje ctive diagnostic criteria were recorded with a more consistent prevale nce than those without Lifestyle data recording was low; overall, smok ing habits and alcohol consumption were recorded for 52% and 38% of pa tients aged over 16 years, respectively. Comparison of the manual reco rds with the computer records showed that the computer records were su fficiently complete with regard to diagnoses (82% of all items recorde d), prescriptions (100%) and referrals (67%), but missed most of the r emaining data that a manual record captured The videorecorded validati on study showed that there were no important lapses in the recording o f diagnoses, prescriptions or referrals when the computer recording wa s compared to the actual process of the consultations Conclusion. In t hese four high-recording practices the data in computer records were o f sufficient completeness and accuracy to allow meaningful data aggreg ation for some diagnoses, prescriptions and referrals. Standardized pr otocols for defining which patients are included and excluded from maj or disease groups are required.