Accuracy of an electronic problem list from primary care providers and specialists.
Accurate patient problem lists in Electronic Health Records (EHRs) are valuable tools for improving the quality of care, communication among professionals, facilitating research, quality measurement and the implementation of clinical decision support systems. However, problem lists are frequently inaccurate and out-of-date, and use varies widely across providers. These deficiencies limit problem list benefits. We decided to check if accuracy of problem lists-assessed at a granular level of detail-registered in EHRs depended on the specialty of the physician (primary care providers vs. specialists), and in the event that such differences did occur, whether or not accuracy had also been affected by the work environment. By using registered problems and taking the generated clinical document, we designed a cross-sectional survey following the guidelines of the Clinical Document Architecture standard. Problems registered by primary care providers have a higher level of accuracy than those registered by specialists in all settings considered (emergency unit, inpatient and outpatient). The work environment also significantly affects the accuracy level of problems registered.
Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina.
Daniel
D
Luna
Mariano
M
Franco
Claudio
C
Plaza
Carlos
C
Otero
Santiago
S
Wassermann
Maria Laura
ML
Gambarte
Diego
D
Giunta
Fernán
F
González Bernaldo de Quirós
D001118:Argentina; D057286:Electronic Health Records / Q000592:standards* / Q000706:statistics & numerical data; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D055991:Health Records, Personal; D019300:Medical Errors / Q000145:classification* / Q000706:statistics & numerical data*; D058007:Physicians, Primary Care / Q000706:statistics & numerical data*; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity