“There’s so much data around. But what data is useful and why is it important to use data to improve patient care?”
In July, AIHW published Australia’s health data 2020: data insights that explore current health data and selected health issues in Australia. This publication recognises data as key to achieving long-term and sustainable improvements in the Australian healthcare system as a whole.
But why is having good quality health data important for GPs? What value does it bring to general practices? And what support is there currently for general practices to undertake data quality improvement practices?
We interviewed our data quality expert, Matthias Merzenich, who has been with Pen CS since 2005. His role as Clinical Quality Assurance Manager includes verifying whether our products meet the national guidelines, ensuring that we are up to date with medications, conditions which we report on, and more.
Read Part 2 of the interview to learn more about:
- What does good quality coded data look like?
- The importance of completeness of data in a patient record
- Questions to ask yourself when entering data
What does good quality data look like?
A complete patient record is a key component of good data.
Completeness of data
If you look at the RACGP accreditation guidelines, it states what should be in a patient record, e.g. allergy status and smoking status.
Some examples which display the potential risk of not properly recording patient data include:
- If you are aware of a life-threatening allergy of a patient of yours, you don’t record it, and the patient then presents at a hospital where staff check their My Health Record.
- If you write a referral letter to someone and you don’t mention the allergy status.
- If a patient sees another clinician at your practice but it’s not recorded properly.
How data is entered
If you’re entering information into the free text progress notes, it is basically lost. Not only for extraction reporting tools but also for a visiting practitioner seeing the patient as they are not immediately familiar with all the details.
If there is vital information hidden in the free text from two years ago, it may also be lost during the limited time in the consultation room.
Patients may accumulate a lot of progress notes over a period of time. If you see a patient, would you read back on ALL of the notes?
Patient records in the clinical information system are designed to capture specific information in their respective fields and that’s where they should be entered.
It’s not about just recording all this vital information, it’s also about how and where you record it and that comes back to the coded diagnoses.
Free text diagnosis of diabetes is better than nothing recorded, but it’s not as good as a properly coded diagnosis. A coded diagnosis of ‘Diabetes’ is good, but a more detailed ‘Type II Diabetes’ diagnosis is better.
Questions to ask yourself
- How much do you record?
- How complete is the patient record?
- How is it recorded?
- Is it recorded in the right place?
Overall, this gives you a better picture to base your diagnosis on and understand what is going on with the patient. Not only for you but also for other clinicians seeing the same patient.
We welcome your ideas and questions. If you have any feedback or questions, please send them to firstname.lastname@example.org.