[Documentation of electronic patient records (EPRS) in German general practices: a telephone survey]. / Elektronische Erfassung von medizinischen Daten in deutschen Hausarzt- praxen: Ein Telefon-Survey.

ABSTRACT

In Germany, use and contents of EPRs are largely unknown and expected to be highly variable, due to missing standards. We conducted a telephone survey to describe and compare computer documentation habits in general practices. Specifically, we were interested in (1) the type of medical data recorded; and (2) which factors influence the extent to which doctors used the EPR while seeing their patients. The sampling frame consisted of family physicians participating in a general practice research project 32% (145/452) of family physicians in the district of Göttingen, Lower Saxony, and 63% (52/83) of physicians from a quality assurance network of family practices in the district of Freiburg, Baden-Württemberg. With the exception of two practices in Göttingen, all practices (n = 165 of 167) took part in this survey. Diagnoses, digital codes for service fees, and prescriptions were computerized in nearly all practices, although doctors were significantly more involved in Freiburg than in Göttingen. Clinical symptoms and findings were recorded in 80% of Freiburg and 52% of Göttingen practices (p = 0.008). Overall, in 74% of Freiburg and 51% of Göttingen practices, the physicians opened the EPR while seeing patients (p = 0.022). Nearly half of the Göttingen practices (49%) and 24% of the Freiburg practices (p < 0.05) entered digital codes for service fees and diagnoses on paper before entering them electronically. In multivariate models adjusting for sex, target group and training specialty, internet access in the office was independently predictive of 'EPR-activity' (OR 2.23; 95%-confidence interval 1.12-4.43). There seems to be room for improvement in terms of degree and intensity of recording of clinically-relevant data. Technical interest, i.e., internet access in the office, seems to enhance electronic documentation activities.