title: Implementation and evaluation of a clinical data management programme in a primary care centre.
abstract: Electronic health records (EHR)support clinical management, administration, quality assurance, research, and service planning. The aim of this study was to evaluate a clinical data management programme to improve consistency, completeness and accuracy of EHR information in a large primary care centre with 10 General Practitioners (GPs). A Clinical Data Manager was appointed to implement a Data Management Strategy which involved coding consultations using ICPC-2 coding, tailored support and ongoing individualised feedback to clinicians. Over an eighteen month period there were improvements in engagement with and level of coding. Prior to implementation (August 2011) 4 of the 10 GPs engaged in regular coding and 69% of their consultation notes were coded. After 12 months, all 10 GPs and 6 nurses were ICPC-2 coding their consultations and monthly coding levels had increased to 98%. This structured Data Management Strategy provides a feasible sustainable way to improve information management in primary care.
authors.affiliation: Livinghealth Clinic Primary Care Centre, Mitchelstown, Co Cork. janice.sweeney@ucc.ie
authors.forename: J
authors.initials: J
authors.lastname: Sweeney
authors.forename: S
authors.initials: S
authors.lastname: McHugh
authors.forename: I J
authors.initials: IJ
authors.lastname: Perry
mesh_terms: D059019:Clinical Coding / Q000379:methods* / Q000706:statistics & numerical data; D016208:Databases, Factual; D057286:Electronic Health Records; D006801:Humans; D007494:Ireland; D011320:Primary Health Care / Q000379:methods* / Q000458:organization & administration*