Groningen A structured registration program can be validly used for quality assessment in general practice

Background: Patient information, medical history, clinical outcomes and demographic information, can be registered in different ways in registration programs. For evaluation of diabetes care, data can easily be extracted from a structured registration program (SRP). The usability of data from this source depends on the agreement of this data with that of the usual data registration in the electronic medical record (EMR). Aim of the study was to determine the comparability of data from an EMR and from an SRP, to determine whether the use of SRP data for quality assessment is justified in general practice. Methods: We obtained 196 records of diabetes mellitus patients in a sample of general practices in the Netherlands. We compared the agreement between the two programs in terms of laboratory and non-laboratory parameters. Agreement was determined by defining accordance between the programs in absent and present registrations, accordance between values of registrations, and whether the differences found in values were also a clinically relevant difference. Results: No differences were found in the occurrence of registration (absent/present) in the SRP and EMR for all the laboratory parameters. Smoking behaviour, weight and eye examination were registered significantly more often in the SRP than in the EMR. In the EMR, blood pressure was registered significantly more often than in the SRP. Data registered in the EMR and in the SRP had a similar clinical meaning for all parameters (laboratory and non-laboratory). Conclusions: Laboratory parameters showed good agreement and non-laboratory acceptable agreement of the SRP with the EMR. Data from a structured registration program can be used validly for research purposes and quality assessment in general practice. Background In general practice the use of electronic medical records (EMRs) instead of paper patient records has become more and more common [1-5]. In an EMR data about a patient's medical history, clinical outcomes and demographic information is recorded. It can provide information about guidelines, patient condition, clinical outcomes and treatment [6]. These benefits from the EMR could result in more efficient and better patient care and care management [7,8]. Published: 21 December 2009 BMC Health Services Research 2009, 9:241 doi:10.1186/1472-6963-9-241 Received: 27 May 2009 Accepted: 21 December 2009 This article is available from: http://www.biomedcentral.com/1472-6963/9/241 © 2009 Fokkens et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. BMC Health Services Research 2009, 9:241 http://www.biomedcentral.com/1472-6963/9/241