Computerisation, coding, data retrieval and related attitudes among Swedish general practitioners—a survey of necessary conditions for a database of diseases and health problems

Abstract

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.

Introduction

Primary health care (PHC) in Sweden is provided by general practitioners (GP), district nurses, and other health professionals at about 1400 health care centres. General practice provides about 12.2 million consultations per year [1]. The use of electronic patient records (EPR) is now almost universal among GPs in PHC, and several different EPR systems are in use [2]. Robust information management is a critical challenge facing the health care industry [3], and a major change in the next decade will centre on gathering, managing, and using clinical information in the EPR systems for all health care areas—administrative, clinical, teaching and research. The agenda for health informatics should address improved quality of public health and possibly lower costs through implementation of evidence based health care. For this purpose, the establishment of a database of health problems and disease management becomes essential [4]. It is, therefore, of interest to study the basic conditions for EPRs in everyday clinical use to prepare the way for such a database.

Ideally the EPR consists of what clinicians have heard, seen, thought, and done [5]. The accuracy of data (correctness and completeness) in EPRs is critical to the optimal outcome of many health care activities, and investigating ways to improve it is considered imperative [6]. The classification and coding of these data must be of high quality, as this is essential for data retrieval [7], [8]. Changes involving data entry are currently taking place, with this work being shifted from coding staff to healthcare professionals [9]. It seems to be of importance to the quality of the coding that doctors take an active part in the coding process [10]. Problems with the process of classifying, defined as ‘the coding of a description of an object by using codes or terms that are designators of the concept in a classification’ [11], are related to activities needed to assign an individual case to the right class and produce the right code in an efficient and reliable way. The reliability of coded diseases is, however, poor both in PHC and in hospital settings [12], [13], [14]. The quality depends on a number of factors, such as coding schemes, coding tools, guidelines, routines, training, and attitudes towards information management as a whole. Evaluation and improvement of the quality of classified and coded clinical information is, therefore, complex.

Due to the need for classification and coding, terminologies have become central elements in health information systems. Swedish GPs have a tradition of using a PHC version of the International Classification of Diseases (ICD) for labelling diseases in the EPR. This is in contrast to most other European countries where the International Classification of Primary Care (ICPC) is utilised [15]. However, the extent to which it is used in everyday clinical practice has undergone little study. A PHC version of the Swedish ICD-10 (KSH97P) was introduced in 1997 [16], [17]. There are a total of 972 codes with preferred terms and 1566 alternative terms in the KSH97P. The chapters are the same as in the ICD-10 except that chapter 20 (external causes of morbidity and mortality) is excluded in the KSH97P.

Research on basic aspects of computers in PHC has been reported during the past decade. The attitudes of GPs towards computerised prescribing of drugs have become more positive [18], and there is a high level of interest in learning various practice-related applications [19]. The primary objective of this study was to investigate the use of computer tools and classifications as well as activities and attitudes related to coding and retrieval among Swedish GPs, which are areas that have received little attention. Results from the survey might serve as a necessary foundation for the establishment of a health care database of diseases and health problems based on EPRs in everyday clinical use. This objective can support future efforts to improve information management in health care.