Journal of Innovation in Health Informatics · 2004 · 290 citations · 0 references
ComputingBiomedical InformaticsHealth InformaticsClinical InformaticsElectronic Health RecordsPrimary CareClinical Data StandardsData ReviewHealth RecordsHealthcare Data StandardsMedical Records ManagementDatabase Quality ControlElectronic Health Record DataElectronic Health Record Data AnalysisFeasibility Study DesignFeasibility Study PreparationHealth Record AuditingMedical Record Quality AssuranceMedical Records Auditing
OBJECTIVES: To build and test a model for the collection of computerised retrospective primary care data from the UK, and to assess its quality for use in medical and pharmaceutical research. DESIGN: Collection and evaluation of sampled retrospective general practice data recording. SETTING: General practices, using the Vision practice management software in the UK. MAIN OUTCOME MEASURES: Quality indicators of completeness of data recording. RESULTS: Initial audit of 236 practices indicated good recording of prescribing in all practices and a high level of completeness of recording of clinical information in many of the practices. CONCLUSIONS: In the group of practices studied, levels of recording were generally assessed to be of sufficient quality to enable a database of quality-evaluated, anonymised primary care records to be created.