ArticleThe British journal of general practice : the journal of the Royal College of General Practitioners1995
Assessment of the completeness and accuracy of computer medical records in four practices committed to recording data on computer.
Article in The British journal of general practice : the journal of the Royal College of General Practitioners, 1995. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 50 papers, 1 of them a synthesis that pooled it.
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Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
50 citing papers in PubMed, 1 synthesis or guideline pooled it.
- Systematic review of scope and quality of electronic patient record data in primary care.BMJ (Clinical research ed.) · 2003Pooled it
- An assessment of morbidity registers for coronary heart disease in primary care. ASSIST (ASSessment of Implementation STrategy) trial collaborative group.The British journal of general practice : the journal of the Royal College of General Practitioners · 2000Trial
- Using set visualisation to find and explain patterns of missing values: a case study with NHS hospital episode statistics data.BMJ open · 2022Article
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- Factors associated with drug survival on first biologic therapy in patients with rheumatoid arthritis: a population-based cohort study.Rheumatology international · 2021Article
- The use of aspirin for primary prevention of cardiovascular disease is associated with a lower likelihood of COVID-19 infection.The FEBS journal · 2021Article
- The basics of data, big data, and machine learning in clinical practice.Clinical rheumatology · 2021Review
- Low plasma 25(OH) vitamin D level is associated with increased risk of COVID-19 infection: an Israeli population-based study.The FEBS journal · 2020Article
- Using standardised patients to assess the quality of medical records: an application and evidence from rural China.BMJ quality & safety · 2020Article
- Concordance Between Electronic Clinical Documentation and Physicians' Observed Behavior.JAMA network open · 2019Article
- A New Insight Into Missing Data in Intensive Care Unit Patient Profiles: Observational Study.JMIR medical informatics · 2019Article
- A conceptual framework for evaluating data suitability for observational studies.Journal of the American Medical Informatics Association : JAMIA · 2018Article
- Substance use and mental diagnoses among adults with and without type 2 diabetes: Results from electronic health records data.Drug and alcohol dependence · 2015Article
- Causes of death in people with liver cirrhosis in England compared with the general population: a population-based cohort study.The American journal of gastroenterology · 2015Article
- Completeness and accuracy of data transfer of routine maternal health services data in the greater Accra region.BMC research notes · 2015Article
- The Intego database: background, methods and basic results of a Flemish general practice-based continuous morbidity registration project.BMC medical informatics and decision making · 2014Article
- Evaluation of data completeness in the electronic health record for the purpose of patient recruitment into clinical trials: a retrospective analysis of element presence.BMC medical informatics and decision making · 2013Article
- Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research.Journal of the American Medical Informatics Association : JAMIA · 2013Review
Corrections and comments
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Authors and funding
3 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
backgroundGeneral practice computer databases are being increasingly seen as a source of data for public health monitoring and commissioning. Such ambitions depend on routine clinical data being recorded with acceptable completeness and accuracy.
aimThe aim of this study was to assess the completeness and accuracy of the computer medical records in four high-recording general practices.
methodFour general practices in the Trent Region that use the EMIS computer system, and were known to be high recorders of clinical data on their computer databases, were selected. A retrospective analysis of the computer records, a prospective comparison of a sample of computer records with manual records, and a prospective comparison between videorecorded consultations and their manual and computer records were undertaken.
resultsChecks for completeness in computer recording of diabetes mellitus and glaucoma showed high levels of accurate recording, 97% and 92% respectively. Prevalence rates between practices were reasonably comparable. No practice consistently, across 10 diagnoses, recorded prevalences higher or lower than the other practices; those diagnoses with recognized objective diagnostic criteria were recorded with a more consistent prevalence than those without. Lifestyle data recording was low; overall, smoking habits and alcohol consumption were recorded for 52% and 38% of patients aged over 16 years, respectively. Comparison of the manual records with the computer records showed that the computer records were sufficiently complete with regard to diagnoses (82% of all items recorded), prescriptions (100%) and referrals (67%), but missed most of the remaining data that a manual record captured. The videorecorded validation study showed that there were no important lapses in the recording of diagnoses, prescriptions or referrals when the computer recording was compared to the actual process of the consultations.
conclusionIn these four high-recording practices the data in computer records were of sufficient completeness and accuracy to allow meaningful data aggregation for some diagnoses, prescriptions and referrals. Standardized protocols for defining which patients are included and excluded from major disease groups are required.
Indexed as
Identifiers
7492423PMC1239405What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.