Accurate and up-to-date data is necessary
Data shared by your organisation and data you receive from other healthcare organisations may be relied upon for clinical decision making. Hence, it is important that you design and implement effective arrangements for maintaining quality patient records.
Documents uploaded to the My Health Record system auto-populate with data (e.g. progress notes, clinical synopsis) from the patient’s local medical record, so it is imperative that the data in your clinical information system is of the highest possible quality.
The Royal Australian College of General Practitioners suggest quality health records have seven attributes:
The following points outline the important relationship between data quality in your organisation and the effective use of digital health:
- Accurate and up-to-date patient identification and demographic information is required in your practice's clinical record system before patient IHIs can be downloaded; and
- The correct IHI is required before patient clinical information can be shared in the My Health Record system; and
- Accurate and up-to-date clinician, staff and organisation identification information is required for your HPI-Is and HPI-O(s); and
- These must be established correctly in your practice also before patient clinical information can be shared.
- Accurate and up-to-date patient clinical information is required in your systems for the safe sharing of health summaries and other clinical documents.
- The sharing of inaccurate data may lead to adverse patient outcomes.
Tips for maintaining quality health records
How you maintain quality records may vary according to your organisation, structure and working methods. Observations from studies suggest the following are useful approaches:
- Allocate time in non-busy periods to check health records.
- Allocate a dedicated resource with medical knowledge to maintain quality health records.
- Verify demographic information with the patient before and during a consultation.
- Use a print-out of the patient health summary to allow the patient to verify its accuracy and suggest amendments between or prior to visits with the clinician.
- Formalise clinical coding and agree standards and conventions for recording patient information on clinical software e.g. using drop-down lists or standard terms.
- Record results and assessments in the right place, including diabetes reviews, health assessments, pap smears, mammogram, faecal occult blood screening and International Normalised Ranges.
- Conduct scheduled audits of health records.
- Archive the records of inactive and deceased patients.
- Use tools through your practice software or middleware solutions.
Data quality is about more than fixing data errors
If data quality improvement is not part of an overall and continuous focus on quality improvement, then your organisation is unlikely to achieve sustainable digital health benefits. In effect, your organisation needs a culture of continuous improvement for these benefits to be sustainable. This approach would, amongst other things, prioritise the prevention of data errors in preference to continual remediation.
Tools for maintaining quality health records
Both Pen Computing Systems (PCS) and the Canning Division of General Practice have developed a free and simple to use tool to help assess, analyse and improve the quality of data contained within most GP clinical software.
The Clinical Data Self-Assessment (CDSA) Tool combines the functionality and capabilities of the Pen Clinical Audit Tool (CAT) and the Canning Data Extraction Tool to allow users to interrogate desktop software and provide a report on data completeness and quality.
The CDSA Tool works with most of the popular desktop software products and can provide your practice with the following functionality:
- Report on completeness of patient demographic and health summary data within the clinical system.
- Report on duplicate patient records within the clinical system.
- Provide a 'dashboard' or traffic light report on data quality status and improvements which can be made over time.
- Provide guidance on addressing identified gaps and improving overall clinical data quality.
Both versions of the CDSA Tool are available for free use. For current licence holders, be sure to download the latest software update to access the CDSA functionality. For non-licence holders, you can download:
Data quality checklist
Data shared by your organisation and data you receive from other healthcare organisations may be relied upon for clinical decision making.
As part of your organisation's planning for digital health, you should design and implement effective arrangements for maintaining quality patient records.