Methods, design and components for a computer-based patient record to promote quality care in general practice

Sammanfattning: Ever since the introduction of the first computer-based patient records (CPR), there have been expectations concerning the potential of CPR not only to support patient care but also to improve its quality. In this thesis methods and models for CPR in general practice are investigated, particularly with respect to possibilities and limitations concerning quality assurance and decision support.A common thread throughout the thesis is the case of the Kronan Health Centre, where the evolution of a working CPR system in primazy care has been demonstrated. Based on the experiences at Kronan, a conceptual model of CPR has been developed which is aimed at meeting the requirements necessary for a system so that it has the desired impact on quality of care. Three basic components constitute the main part of the model: a patient database, a data dictionary and a medical knowledge base. A structured and standardized CPR is advocated. A controlled medical vocabulary, represented in the model by the data dictionary, is the component that links the patient database and the medical knowledge base together.The empirical part of the thesis is based on two retrospective database studies and two audit studies. In these studies, the primary data source has been the patient database at the Kronan Health Centre, and the primary method of data collection has been database querying using amedical query language. The main empirical results of the studies are: I) There is a relation between diabetes and hypertension (which is in accordance with the hypothesis of a common metabolic syndrome); 2) Potential dmg interacrions occur at a higb rate in general practice, particularly in elderly patients; 3) Medical audit perfurmed with the particular method described can improve patient care within a short term perspective as well as in the long run; 4) Use of CPR facilitates the review of medical records that is needed in audit.A framework for CPR-based quality assurance in primary health care is proposed. The role of CPR within this framework is to facilitate initial and repeated data collection and data analysis and to make feasible an integration of a quality system into routine practice. Based on the conceptual model and on the implications of the empirical studies, a CPR system with integrated decision support has been developed and implemented at the Kronan Health Centre. Decision support has been focused on the real needs of the practitioners and on management rather than diagnosis. Computer reminders related to drug prescribing and computerized care protocols constitute the concurrent audit part of the quality system.