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Computerisation, coding, data retrieval and related attitudes among Swedish general practitioners-a survey of
Gunnar Nilsson1, Hans Ahlfeldt, Lars-Erik Strender
1Department of Clinical Science, Family Medicine Stockholm, Karolinska Institutet, Novum, SE-141 57 Huddinge, Sweden. gunnar.nilsson@nlpo.sll.se
Objective:
To investigate necessary conditions for the establishment of a database of diseases and health problems for research and health care planning, based on electronic patient records in everyday clinical use among general practitioners (GPs).
Design:
Postal questionnaire study.
Setting:
Primary health care in Sweden.
Subjects:
Three hundred randomly selected GPs.
Main Outcome Measures:
Degree of computerisation of patient records. User frequency and characteristics of diagnosis classification systems and coding tools. Frequency of coding activities and retrieval of codes, and related attitudes. Opinions on a primary health care version of ICD-10.
Results:
A total of 184 GPs (61% of the 300 GPs) were included in the study. About 92% used an electronic record system, some type of diagnostic classification was used by 93%, and ICD based classifications by 88%. The classification in use was computerised for 74%. Mainly simple tools were used to retrieve diagnostic codes. About 76% of GPs reported classifying at least one symptom or disease per encounter. The codes were retrieved 'once a month' or more by 19%. Classification of diseases was considered important for follow-up by 83%, and for the care of the patient by 75% of the GPs. The primary health care version of ICD-10 with a total of 972 codes was considered too limited in size by 31%.
Conclusion:
Electronic patient records in everyday clinical use in Swedish general practice provide several fundamentals for a database of diagnostic data. However, there are several barriers to the establishment of such a database that is both valid and reliable.
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