The influence of electronic reminders on recording diagnoses in a primary health care emergency department: a register-based study in a Finnish town

摘要

Objective This study examines whether implementation of electronic reminders is associated with a change in the amount and content of diagnostic data recorded in primary health care emergency departments (ED). Design A register-based 12-year follow-up study with a before-and-after design. Setting This study was performed in a primary health care ED in Finland. An electronic reminder was installed in the health record system to remind physicians to include the diagnosis code of the visit to the health record. Subjects and main outcome measures The report generator of the electronic health record-system provided monthly figures for the number of different recorded diagnoses by using the International Classification of Diagnoses (ICD-10th edition) and the total number of ED physician visits, thus allowing the calculation of the recording rate of diagnoses on a monthly basis and the comparison of diagnoses before and after implementing electronic reminders. Results The most commonly recorded diagnoses in the ED were acute upper respiratory infections of various and unspecified sites (5.8%), abdominal and pelvic pain (4.8%), suppurative and unspecified otitis media (4.5%) and dorsalgia (4.0%). The diagnosis recording rate in the ED doubled from 41.2 to 86.3% (p < 0.001) after the application of electronic reminders. The intervention especially enhanced the recording rate of symptomatic diagnoses (ICD-10 group-R) and alcohol abuse-related diagnoses (ICD-10 code F10). Mental and behavioural disorders (group F) and injuries (groups S-Y) were also better recorded after this intervention. Conclusion Electronic reminders may alter the documentation habits of physicians and recording of clinical data, such as diagnoses, in the EDs. This may be of use when planning resource managing in EDs and planning their actions.KEY POINTS Electronic reminders enhance recording of diagnoses in primary care but what happens in emergency departments (EDs) is not known. Electronic reminders enhance recording of diagnoses in primary care ED. Especially recording of symptomatic diagnoses and alcohol abuse-related diagnoses increased.