Towards improvement of the accuracy and completeness of medication registration with the use of an electronic medical record (EMR)

Background. Approximately 80% of GPs use a GP information system (GIS) and an electronic medical record (EMR) in their daily practice. To reap the ful l benefits of an EMR for patient care, post-graduate education and research , the data input must be well structured and accurately coded. Objectives. The quality and user-friendliness of the software positively in fluence the completeness and reliability of the data recorded in the GIS. T o assess this in actual practice, this study examined whether or not an inc rease occurred in the accuracy and completeness of indication-related medic ation registration after the GIS's software package was upgraded. Method. GPs recorded data for the Registration Network Groningen (RNG) conc erning four medication groups: insulin, trimethoprim. the contraceptive pil l and beta -blocking agents. The completeness and accuracy of the registere d data were assessed both before and after the change to the new software p ackage. The completeness is evaluated on the basis of the indications missi ng for the prescribed medications. To assess accuracy, a check was made to determine whether the indications corresponded to those deemed relevant for that particular medication according to National Pharmaceutical Guidelines . Results. The percentage of missing indications decreased notably, especiall y in the chronically prescribed medication groups. For insulin, the percent age decreased from 40.5 to 3% and for the contraceptive pill from 34.5 to 1 %. For trimethoprim, the percentage decreased from 10 to 1%, and for beta - blocking agents from 22 to 1.5%. Of the indications present, the percentage of relevant indications showed a slight increase, with the largest increas e observed for the contraceptive pill where the percentage rose from 86 to 96%. Conclusions. The completeness of recorded indications improved considerably after the change of software. This is due mostly to the efforts of the GPs , their practice assistants and the support of the RNG organization involve d in the conversion procedure. Accuracy improved slightly, especially due t o the software modifications which ensured that non-existent codes could no t be entered. To summarize, with increased user-friendliness of the softwar e, combined with the training of motivated GPs, the quality of recorded dat a improved.