Dataset Information

The quality of electronic patient records in Finnish primary healthcare needs to be improved.

ABSTRACT: OBJECTIVE: To analyse the technical quality of electronic patient records in relation to legislation and to evaluate their quality associated with the quality of consultations as rated by patients and GPs. DESIGN: Cross-sectional study of electronic patient records. SETTING: Four primary healthcare (PHC) centres in Finland using three different electronic patient record systems. SUBJECTS: Patient records of 175 PHC consultations by 50 GPs, rated as the best (n=86) and the worst (n=89) of a total of 2191 consultations. MAIN OUTCOME MEASURES: Documentation of records compared with legislation, the general informative value of records, and its relation to the experienced quality of consultations and to the electronic system employed. RESULTS: Reason for encounter was mentioned in 79% of cases and patient history in 32%. An acute problem was described moderately well or well in 84%, examination findings in 62%, medical problem or diagnosis in 90%, and treatment in 95% of cases. Medication was documented adequately in 38% of the cases where medication was documented. Concerning general informative value, 18% were assessed as poor, 62% as moderate, and 20% as good. No correspondence was found between experienced quality of consultation and general informative value in the patient records. The quality of patient records was found to change according to the electronic system employed. CONCLUSIONS: Finnish patient records are inadequate documents of consultations and below the standard of that country's legislation. Developing better models of recording would guarantee a higher quality of work.

SUBMITTER: Vainiomaki S

PROVIDER: S-EPMC3406647 | biostudies-other | 2008

REPOSITORIES: biostudies-other

ACCESS DATA

Similar Datasets

Project description:BackgroundThere is increasing awareness of the importance of patient activation (knowledge, skills, and confidence for managing one's health and health care) among clinicians and policy makers, with emerging evidence showing higher levels of patient activation are associated with better health outcomes and experiences of health care. This study aimed to examine the association between patient activation and a wide range of specific types of healthcare service utilisation in England, including GP and non-GP primary care, elective and emergency hospital admissions, outpatient visits, and attendances at the Accident and Emergency department.MethodsData were derived from linked electronic patient records collected by primary and secondary healthcare providers in North West London between January 2016 and November 2019. Our analyses focused on adults (18+) with a valid Patient Activation Measure (PAM). After excluding patients with missing data, we had an analytical sample of 15,877 patients. Data were analysed using negative binomial regression and logistic regression models depending on the outcome variable.ResultsPatients had a mean activation score of 55.1 and a standard deviation (SD) of 17.7 (range: 0-100). They had an average of 5.4 GP visits (SD = 8.0), 26.8 non-GP visits (SD = 23.4) and 6.0 outpatient attendances (SD = 7.9) within a one-year follow-up. About 24.7% patients had at least one elective admission, 24.2% had one or more emergency admissions, and 42.3% had one or more A&E attendance within the follow-up. After accounting for a number of demographic and health factors, we found a linear (or proximately linear) association between patient activation and the number of GP visits, emergency admissions and A&E attendance, but a non-linear relationship between patient activation and the number of non-GP visits, the number of outpatient attendance and elective inpatient admission.ConclusionsThis study has provided strong empirical evidence from England linking patient activation with healthcare service utilisation. It suggests the value of supporting patient activation as a potential pathway to ease the burden of healthcare system.

Project description:BackgroundEmbedding patient accommodation need in the electronic health record (EHR) has been proposed as one means to improve health care delivery to patients with disabilities. Accommodation need is not a standard field in commercial EHR software. However, some medical practices ask about accommodation need and store it in the EHR. Little is known about how the information is used, or barriers to its use. This exploratory-descriptive study examines whether and how information about patients' disability-related accommodation needs stored in patient records is used in a primary health care center to plan for care.MethodsFour focus groups (n = 35) were conducted with staff of a Federally Qualified Health Center that asks four accommodation questions at intake for the EHR. Respondents were asked how they learned about patient accommodation need, whether and how they used the information in the EHR, barriers to its use, and recommendations for where accommodation information should reside. A brief semi-structured interview was conducted with patients who had indicated an accommodation need (n = 12) to learn their experience at their most recent appointment. The qualitative data were coded using structural coding and themes extracted.ResultsFive themes were identified from the focus groups: (1) staff often do not know accommodation needs before the patient's arrival; (2) electronic patient information systems offer helpful information, but their structure creates challenges and information gaps; (3) accommodations for a patient's disability occur, but are developed at the time of visit; (4) provider knowledge of a regular patient is often the basis for accommodation preparation; and (5) staff recognize benefits to advance knowledge of accommodation needs and are supportive of methods to enable it. Most patients did not recall indicating accommodation need on the intake form. However, they expected to be accommodated based upon the medical practice's knowledge of them.ConclusionsPatient accommodation information in the EHR can be useful for visit planning. However, the structure must enable transfer of information between scheduling and direct care and be updatable as needs change. Flexibility to record a variety of needs, visibility to differentiate accommodation need from other alerts, and staff education about needs were recommended.

Dataset Information

The quality of electronic patient records in Finnish primary healthcare needs to be improved.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets