EMR and administrative data both needed for full perspective of patient
Data capture completeness within primary care EMRs is comparable with administrative data, with the advantage that EMRs contain lab results, prescription information and detailed clinical information. However, the combination of complete EMR records and administrative data is needed to provide a full comprehensive picture of patient health histories and processes, and outcomes of care, according to a study published in the American Journal of Managed Care.
The study, “Evaluation of Electronic Medical Record Administrative Data Linked Database,” conducted by researchers at the Institute for Clinical Evaluative Science in Toronto, Canada, found that primary care EMRs have reasonably comprehensive capture of primary care physician visits, lab tests and prescriptions. However, lab tests and prescriptions by outside providers often are missing due to inadequate communication with specialists, and poor communication between EMRs and hospitals, according to the study.
The researchers conducted a retrospective comparison of provincial health-related administrative databases and patient records within the EMR Administrative Data Linked Database (EMRALD) for more than 50,000 patients of 54 physicians in Ontario, Canada. Among the findings:
- The mean percentage of clinic primary care outpatient visits captured in EMRALD compared with administrative data was 94.4 percent
- The mean capture within EMRALD of the most common laboratory tests billed and the most common drugs dispensed was 67.3% and 68.2%, respectively, for all clinics.
- Letters from specialists for first consultations and for hospital discharges were captured at a mean rate of 72.7 percent and 58.5 percent, respectively, within 30 days of the occurrence
“Until integrated systems with open communication channels between all aspects of the healthcare system are in place, the most comprehensive patient health histories can be achieved by combining information from complete EMR records and administrative data,” wrote Karen Tu, MD, MSc, Clinical Evaluative Science, et al.