How can we improve the quality of data collected in general practice?

The primary purpose of general practice electronic health records (EHRs) is to help staff deliver patient care. Documentation facilitates continuity of care and allows symptoms to be tracked over time.12 Most information is entered into the electronic record as unstructured free text, particularly during time pressed consultations.3 Although free text provides a mostly adequate record of what has taken place in clinical encounters, it is less useful than structured data for NHS management, quality improvement, and research. Furthermore, free text cannot be used to populate problem lists, calculate risk scores, or feed into clinical management prompts in electronic records, all of which facilitate delivery of appropriate care to patients.

Creating high quality structured data that can be used for health service planning, quality improvement, or research requires clinical coding systems that are confusing to many clinicians.456 For example, coding can seem rigid in ascribing concrete labels to symptoms that may be evolving or of diagnostic uncertainty.7 It is time consuming for staff to process external inputs to the electronic record, such as letters from secondary care, and if this is done by administrators, comprehension of clinical information may be a further barrier to high quality structured data entry.8 The content of digital communications such as text messages from patients to clinicians, emails, and e-consultations may also need to be converted to structured data, even if the communication exists in the electronic health record. This all represents additional work for clinicians with seemingly little direct incentive for patients. As frontline clinical staff are usually not involved in the secondary uses of data, such as health service development …