General practitioner records on computer--handle with care

• HIT Description: Electronic health record. More info...
  
• Purpose of Study: Determine how accurately doctors record laboratory investigations on computer and compare the effectiveness of three interventions in improving the completeness of computerized recording.
  
• Years of study: 1989-1990
  
• Study Design: RCT
  
• Outcomes: Impact on health care effectivness/quality, Impact on health care access
  

• Settings: Nine general practitioners and a total of 7983 patient contacts were analyzed in an urban health centre
• Intervention: The three interventions compared with a manual record were: informal individual meeting with no feedback of results, informal individual meeting with feedback, and formal group meeting with feedback.
• Evaluation Method: Measures of physicians' encounters (an individual consultation), and documentation.
• Healthcare Utilization: The intervention physicians saw in consultations a significantly higher proportion of their patients.
• Quality of Care and Patient Safety Outcome: Intervention led to an improvement in the recording of presenting symptoms and problems/diagnoses. Recording of investigations on the computer showed no improvement, remaining at one-third of the total in the treatment room book for both study and control doctors. The effectiveness of the different forms of intervention depended on both the aspect of the consultation considered and the familiarity of individual doctors with the method of data collection. Aspects considered less important required greater intervention to bring about a marked improvement, as did doctors relatively new to the practice