Disease and intolerability documentation in electronic patient records

Area of Science:

• Pharmacy practice
• Health informatics
• Medication safety

Background:

• Accurate documentation of diseases and intolerabilities in electronic patient records (EPRs) is crucial for preventing contraindicated medication prescriptions.
• Limited research exists on the status of EPRs within pharmacy settings.

Purpose of the Study:

• To investigate the prevalence and quality of disease and intolerability documentation in EPRs.
• To assess documentation completeness and reliability for specific conditions in Dutch community pharmacies.

Main Methods:

• A cross-sectional study involving 79 Dutch community pharmacies.
• Data collected on demographics, drug use, and documented diseases/intolerabilities for 687 patients over one day.
• Analysis of documentation sensitivity (completeness) and positive predictive value (reliability).

Main Results:

• At least one disease was documented in 57.4% of EPRs; intolerabilities in 7.9%.
• Higher patient age, increased medication use, and higher chronic disease scores correlated with documentation.
• High sensitivity for diabetes (84.7%), asthma/COPD (75.9%), and hypothyroidism (75.0%); lower for heart failure (29.4%).
• High reliability for hypothyroidism (100%) and diabetes (87.1%).

Conclusions:

• Nearly 60% of patients in the sampled Dutch pharmacies had documented diseases and/or intolerabilities in their EPRs.
• Documentation quality varies significantly across different diseases.
• Enhancing the frequency and quality of documentation is essential for effective drug-disease interaction surveillance in pharmacies.