Patients, diagnoses and processes in general practice in the Nordic countries. An attempt to make data from computerised medical records available for comparable statistics

Abstract

Objective: To try out a collection of a standard set of data from computerised medical records.

Design: Retrospective extraction of ordinary patient record information put into the computer by general practitioners.

Setting: Encounters in office hours in strategically selected practices or health centres in Denmark, Finland, Iceland, Norway and Sweden.

Subjects: 59 general practitioners and a total study population of 97475 persons.

Main outcome measures: Proportions, crude and specific rates of encounters, diagnoses and processes.

Results: In a 4-week period there was a threefold difference in the office encounter rates between the participating sites in the Nordic countries. Gender and age patterns were similar despite these differences. An access to several different denominators revealed diverse patterns of referring to the specialist, prescribing, ordering blood tests, X-rays and physiotherapy. Data from computerised medical records agree well with earlier studies in the Nordic countries using other methods.

Conclusions: This survey demonstrates that valid and reliable data for routine statistics are available from computerised medical records in general practice. The major obstacle extracting more epidemiological data from computerised medical records is caused by information in the databases not being uniquely linked to episodes of care.