Electronic Patient Records

In the Literature

Jones-Diett J, Robinson N, Cobb M, Brennan M, Dean RS. Accuracy of the electronic patient record in a first opinion veterinary practice. Prev Vet Med. 2016. doi: 10.1016/j.prevetmed.2016

The Research …

Understanding the validity and reliability of electronic patient record (EPR) data is critical to the interpretation and application of research results. New knowledge and evidence generated from general practice populations likely have greater clinical relevance and generalizability than does evidence generated from tertiary care or referral populations.

Over a period of 5 days, 36 companion animal–veterinary encounters were observed by 2 researchers at a first-opinion practice to compare data entered into the EPRs with data collected from direct observation. Data captured from patient encounters for comparison included signalment, number and order of problems discussed, type of problem (ie, new, pre-existing, preventive), who raised the problem (ie, pet owner vs veterinarian), and action taken (eg, therapy, prophylaxis, management, diagnostic investigation, euthanasia). Just more than two-thirds (64.4%) of the problems directly observed during patient visits were also recorded in the EPR. Significant differences between direct observation and the EPR were revealed in the order the problem was addressed, who raised the problem, problem type, and action taken.

All problems discussed first during the patient encounter were also recorded in the EPR, as were problems triggered by a prompt (eg, vaccination reminder). Preventive medicine problems (89.3%) were most likely to be recorded in the EPR, followed by pre-existing problems (65.6%) and new problems (46.2%). Actions resulting in prophylactic treatment, diagnostic investigation, or euthanasia were all reported completely in the EPR. Lesser degrees of concordance between data recorded in the EPR and that directly observed were noted for therapeutic action (71.4%), management action (35.3%), or no action taken (25.7%).

Understanding the degree to which EPRs accurately reflect the veterinary general practice encounter is critical to the interpretation and application of the results generated by population-based studies. Dual value is derived from accurate EPR reporting for both the quality of patient care and research. The practice of evidence-based veterinary medicine demands quality research to generate new knowledge.

… The Takeaways

Key pearls to put into practice:

• The EPR should be fully leveraged when entering clinical data (eg, problems, diagnoses, treatments) so that quality patient care and future population research are optimized.

• Problems and diagnoses in the EPR should be linked to client handouts and reminders as an incentive to enter pet health information into the system and drive client satisfaction.

• Practice team members should be enlisted in the patient workflow for EPR data entry to optimize operational efficiency.