Entering accurate information into your computer is essential not only for healthy practice finances but for good patient care too, as Dr Gillian Braunold explains

Thanks to computers, we can take and manage notes more easily and efficiently than ever before. However, the flip-side of this revolution in working practice is that small inputting errors can cause major problems when the data are processed and accessed.

GPs are now seeing the fruits of their labour in coding their quality and outcomes framework (QOF) data. Practices are receiving funding based on the performance data they have submitted to the Quality Management and Analysis System (QMAS). Audit of the data enables outcomes to be measured, encouraging practices to improve the quality of care they deliver.

Getting the most from the computer

The strength of the computer lies in its ability to process massive amounts of information. It can deliver guidelines customised locally or by the practice to the GP, thereby supporting decision making in the consultation. It also saves GPs from manually reproducing information. However, computers can only replicate the data that have been entered and as the information can be retrieved and used in many settings, there are many opportunities for any errors to proliferate.

Many clinicians follow their first instincts when they switch from paper to PC records, using free text as much as possible. They appreciate the ease with which they can retrieve their notes and their legibility.

However, using free text will prevent doctors from fully exploiting the potential of IT, because it is difficult to retrieve and audit.We can reap the full benefits of computerised data only when the coding is accurate.

The impact of coding errors

It is common to see coding errors that may seem insignificant to the casual observer but, when the data quality is assessed, are found to have major significance.

Data only become information when entered appropriately, into the correct position, in an electronic record. Incorrectly entered data are irrelevant and potentially dangerous. The following example illustrates this.

A new patient joins the practice. She is not an asthma sufferer, although her mother is. The practice nurse enters the code for ‘History of asthma’ into the record and adds, in free text, that the patient’s mother has asthma.This is incorrect because the history relates to the family member and not to the new patient, to whom the code should relate.

Instead, the practice nurse might have entered the code for ‘Asthma’ and added in free text that the patient’s mother had asthma. However, this is also incorrect.

Any search on either of these codes will wrongly identify the new patient as suffering from asthma. In fact, the correct way to code this patient’s notes is ‘Family history of asthma’. Free text could then be used to identify the patient’s mother as the asthma sufferer (see Figure 1, below).

Figure 1: Screen shot showing examples of correct and incorrect coding for a fictitious patient with a family history of asthma

The forms of coding described above would appear in the medical records as:

  • H/O: asthma – mother has
  • Asthma – mother has
  • FH: asthma – mother has.

The difference appears small, but from a search and reporting perspective it is huge.

The importance of accurate data

Few receptionists, IT administrators, administrative assistants or clinicians understand these subtle but critical distinctions. Even after more than 15 years of using codes in general practice,there is still an enormous need for training in how to do this work properly and abandon bad habits.

However, good practice guidelines have been issued by the Department of Health, and practices that enter clinical data on their computers should comply with these (see Box 1, 2 and 3 below).

Box 1: Ensuring that data are complete, accurate and relevant

Good practice guidelines for general practice electronic patient records recommend that practices should consider:

  • Training for GPs and other practice staff involved in data capture
  • Identifying someone to lead on preparing the practice for participation in IT implementation and development
  • Undertaking a baseline assessment which will enable the practice to understand what changes need to be made
  • Reviewing and changing procedures to ensure completeness and consistency of data capture

To ensure complete, accurate and relevant data, practices should consider the following:

  • Can any data such as demographic information be downloaded to populate the clinical system?
  • High quality data should be:
    • Complete
    • Accurate
    • Relevant
    • Accessible
    • Timely
  • The primary purpose of recording information is to support patient care
  • All clinicians should participate in data recording
  • All clinicians should enter their own data directly into the clinical system
  • What data are not recorded at all (or not consistently) on computer by some or all clinicians?
  • What data come from other PHCT members, such as community and practice nurses and how should they be captured?
  • How to capture data from locums, registrars and home visits?
  • How are data gathered when new patients register with the practice?
  • How will protocols of care and/or diagnostic criteria (where available) be used and made acceptable to the practice as a whole?
  • Who will design, develop and implement templates or protocols? (where available)
  • How will data obtained from elsewhere (such as hospital discharge letters) be managed?
  • How will the practice manage if the IT system goes down?
  • How will data quality be monitored?
  • Is electronic data interchange for pathology, radiology etc. available from local hospitals and how will the practice manage the implementation?

Practices should develop systems for:

  • Retrospective data recording
  • Prospective data recording (recording all consultations)
  • Recording clinical codes
  • Direct data entry
  • Indirect data entry
  • Non-routine data capture ¨Use of templates and protocols
  • Linking data items (e.g. treatment, medication, referral)
  • Contacts outside the surgery and interventions carried out elsewhere
  • Referrals, clinical letters and investigations
Box 2: Practice education and training needs

Good practice guidelines recommend that practice staff should receive training in:

  • How to use the technology
    • Keyboard skills
    • Using office programmes
    • Using the clinical system
    • Conforming with local practice
    • How to get help if the system fails
  • Data, information and meaning
    • How to use coded and free text entry appropriately
    • Understanding how context affects the interpretation of data
    • How to apply that understanding when receiving or sending messages
    • Awareness of the purposes to which a particular entry may be put
    • Understanding the issues of information governance
    • Understanding the importance of consistency and accuracy in data entry
    • Conforming with local practice
  • Integrating electronic and interpersonal communication of information
    • Awareness of how computer use affects the consultation
    • How to use communication skills to relate to the patient while using the computer
    • How to facilitate shared reading from the computer screen
    • How to incorporate outside knowledge (from the computer) into the consultation: learning, teaching, facilitating
    • How to share information and decision making
Box 3: Sources of further information
  • Good practice guidelines for general practice electronic patient records (version 3.1) sponsored by the Department of Health and prepared by the joint general practice information technology committee of the GPC and the RCGP are available from the Department of Health website: www.dh.gov.uk
  • Clinicians interested in the discussion on the content of the summary record and the role of general practice in its evolution will find information on the Care Record Development Board website: www.connectingforhealth.nhs.uk/crdb/

Until now, coding errors had significance only for the practice that entered the information. No lasting damage was done by a carelessly entered code.

During a quality visit to a practice, I was examining a set of notes on which codes for seven different types of malignancy and one for hypothyroidism had been entered, all on the same day.

On looking at the manual set of notes, which had clearly been ‘summarised’, the underlying errors became apparent.

Details of the patient’s family history of malignancies had been given ‘B2’ hierarchy codes – malignancy codes – instead of ‘family history’ hierarchy codes.

Instead of the date of diagnosis of hypothyroidism recorded on the manual records, the summariser had entered the date when the summary was made.This date was also entered as the date of diagnosis of the cancers.

The impact of errors like these will be felt in various ways now that data are starting to flow electronically from one part of the health service to another.

Capitalising on accurate data collection

During the coming year, the GP2GP project will start to roll out.This will enable practices to send electronic records direct to patients’new practices when they move to another area.The benefits to both patients and practices are immense.

Speedy transfer of notes is eagerly anticipated. Notes summarised by one practice can be sent to the patient’s new one, thus eliminating the need to repeat the time-consuming process of summarising.

QOF data can also be transferred by this means.Accurately coded data will then be paramount, because not only will patients’ notes be transferred from one practice to another, but the codes on which practices base their QOF points – and therefore their funding – will be transferred as well.

During the second half of 2006 the summary record will be generated, and general practice will be a major source of the information it contains.

The National Clinical Leads for General Practice within Connecting for Health are suggesting that practices be accredited for their standards of data entry before they supply data for the summary record.

We are arguing that the quality of the summaries the practices are signing off for their QOF points should meet those standards (see Box 3 above).


The ‘rubbish in, rubbish out’ adage of the IT world is true.The quality of the data we use depends greatly on the quality and accuracy of the information entered onto the computer in the first place.

GPs need to validate data and clinical information with their patients during the consultation and ensure that the data are correctly coded when entered onto the computer.


Guidelines in Practice, September 2005, Volume 8(9)
© 2005 MGP Ltd
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