GPs are wide of the ideal in patient information management and completeness, a study has found.
As one example, 14% of the 85 practices surveyed failed to meet a standard which stipulates that “50 to 75% of [patient] records have adequate information”, says the study, conducted by the Royal New Zealand College of General Practitioners between November 2000 and June this year.
The study was part of the lead-up to a document setting out acceptable standards for general practice. Entitled “Aiming for Excellence in General Practice”, the document is designed “to help you [practitioners] put a cross on the map that says where your practice is, and decide where you want to go.”
Standards project manager Maureen Gillon is hesitant to criticise GPs for the apparently low standard of information completeness. “I wouldn’t describe it as a ‘falling short’,” she says, “but there is clearly room for improvement.” The college now knows better where practices are and can help them improve, and guide them in helping themselves to improve, she says.
GPs’ standards priorities have, until recently, been on matters directly related to patient care, Gillon suggests. Now other “pressures” have been brought to bear, in areas like good business processes and information management.
The standards document stipulates what information should be collected for a “complete” record, spells out privacy and security standards — for example, “medical records and documents (paper or computer) are not visible in public areas ... Non-lockable files (or not-secure computers) are in staff areas only”, and that records are seen and checked for accuracy by appropriate staff.
The project is concentrating on the accreditation process and training of staff to conduct audits on GPs who wish to be audited externally, so no work has yet been done on specific recommendations for methods and software tools to improve, Gillon says.
The college is working on a second volume of the “Aiming for Excellence” document, which will cross-reference the criteria with standards produced by other bodies such as the Standards Association of New Zealand.