Health Record data quality
Health record data quality
Trina: So the reason we need good, clean, health data and good records on our patients are not only just for local reasons, but for sharing reasons as well. Locally we need good records because we use our data for clinical decision support. So if the data isn't coded or isn't accurate or up-to-date we miss out on those decision-support safety networks. I think it's respectful to other people as well because you're not the only person in your practice that's going to be using that patient’s records. There's other GPs, and the nurse, and you might have locums when you go on holiday… So it's respectful to the patient and to the other care providers to make sure that your notes are useful and clean and up to date.
We use our practice for population health as well, so if the information is not there then you can't do population health in your practice. And more and more we're sharing information about our patients with other providers, to different organizations, to shared health records to various different providers. So the information needs to be useful to make their job as easy [as possible] and deliver the safest health care they can for the patient to. So we also try and foster a culture within our practice of respect of the patients and respects of the other providers. So it's because I respect you as another GP or because I respect my practice nurse - I want them to work off the best quality data that I can provide for them If they're seeing a patient that I've seen. It’s also respect for the patients as well because they trust us with our information, so we really have a duty of care to keep it current and clean and accurate.
The quality of patient health records kept by general practices is an important factor in safe and effective healthcare.
The primary purpose of a clinical health record is to hold the information about a patient that is required for effective care: good patient information supports appropriate clinical decisions. With changes to the way primary care is delivered, including increasing use of shared care models and eHealth records (My Health Record), the quality of this information is more important than ever. No longer serving only individual general practitioners (GPs) or practices, information in a patient’s health record is likely to be shared between and relied upon by primary, secondary and tertiary healthcare services.
General practice health records serve a number of purposes, including providing data for research and policy, contributing to education, and providing healthcare evidence for medicolegal purposes. All these uses depend on records containing high-quality information that is accessible to appropriate users.
Yet maintaining high-quality health records is not always regarded as a priority by general practices or GPs. Competing demands on busy clinicians and practice staff mean the importance of health record quality is often overlooked, and some may not be aware of what is expected of health records.
The Royal Australian College of General Practitioners (RACGP) has produced this guide, outlining what constitutes a high-quality health record and how practices can put systems in place to ensure they produce health records that are fit for purpose.
Benefits of high-quality health records
Maintaining high-quality health records has benefits for patients, GPs, the practice and the wider community.
For patients, the quality of their health information kept by a practice can affect their healthcare outcomes, as it informs decisions about their treatment and facilitates continuity of care (both within the practice and between other services). High-quality records also make it easier for patients to access and understand their healthcare information.
For individual GPs, high-quality health records allow them to effectively communicate with their colleagues and other health professionals. They allow GPs to take full advantage of clinical information systems to manage patient follow-up more efficiently – through reminders or recalls – for particular patient populations. GPs may also rely on health records in defending against medico-legal claims.
For general practices, high-quality patient health data is becoming more and more essential for quality improvement activities – whether this be carried out by a practice itself or in collaboration with an external agency (eg participation in NPS MedicineWise’s Medicine Insight program). It also allows a practice to better understand and identify its own patient cohort. This supports more effective healthcare delivery at both an individual and local population level.