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• A whole healthcare record
  Susan M Dovey
  Published on: 22 January 2004

• Published on: 22 January 2004

  A whole healthcare record

  • Susan M Dovey, Primary Care Research
  • Other Contributors:
    • Chair, The Linnaeus Collaboration

  Dear Editor

  At the Linnaeus Collaboration meeting in Canberra, Australia last week (sponsored by the Australian Primary Health Care Research Institute and the US Agency for Healthcare Research and Quality), primary care researchers from Australia, Canada, England, Germany, New Zealand, and the United States met to consider further research aimed at improving patient safety in primary health care. We discussed the...

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  Dear Editor

  At the Linnaeus Collaboration meeting in Canberra, Australia last week (sponsored by the Australian Primary Health Care Research Institute and the US Agency for Healthcare Research and Quality), primary care researchers from Australia, Canada, England, Germany, New Zealand, and the United States met to consider further research aimed at improving patient safety in primary health care. We discussed the issues raised in the editorial by RM Wilson because we also think that improvements in medical record-keeping are crucial to improving patient safety. From our discussion, the following was clear:

  1. Paper medical records are not a viable phenomenon for the 21st century and beyond. This is a particularly challenging notion for the countries in North America and Australia, where there has not yet been a wholesale clinical and political commitment to electronic medical records.

  2.. The medical record of the 21st century may well be patient held and maintained. As researchers we found this idea worrying because medical records are a rich and valuable research resource - we worry that they may become so well disintegrated that they may no longer be available for research.

  But to answer Wilson's questions: 1. We agreed that the key functions of the medical record are to keep a record of all encounters between patients and the formal health system. This record may then be used: (1) to maintain patient safety by ensuring that health information about a patient exists and is accessible to those who need it - at any time and in any place, (2) to identify early signs of catastrophic events (e.g. bioterrorism) through sentinel monitoring, (3) to measure costs and benefits of healthcare in the real-world setting, and therefore (4) in light of the above, to be a continuous healthcare quality improvement tool.

  2. What constitutes a "minimum" dataset for a patient record has already been considered (e.g. [1]). To best fulfil all its functions, medical records should hold full information about each healthcare encounter, including setting and encounter method (face-to-face, phone, email, video, etc), dates, both patient and provider views of reason for encounters, and details of care provided (including information about medications, investigations, referrals, immunisations, and other preventive measures). There is disagreement between countries on the extent of patient information that is necessary in a patient's medical record. For instance, in New Zealand the government is concerned that patients' ethnicity and residence location (for calculating deprivation and measuring inequalities) are recorded - neither piece of information having particular significance for gps' clinical decisions. No other country represented at the meeting had to provide these particular items, but in the US and Germany health insurance information is absolutely required. There will obviously be international variation in "key" elements.

  3. How do we implement such requirements? Marshall and Smith write persuasively in this issue of financial incentives [2]. While we agree that financial incentives are necessary for systemwide adoption of medical records standards, we also think political will, a rationale that is credible to healthcare providers, and cultural change in practice are crucial.

  References

  1. Tilyard MW, Munro N, Walker SA, Dovey SM. Creating a general practice national minimum data set: present possibility or future plan? NZ Med J 1998; 111: 317-20.

  2. Marshall M, Smith P. Rewarding results: using financial incentives to improve quality. Qual Saf Health Care 2003; 12(6): 397-8.

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  Conflict of Interest:
  None declared.

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