How do I Care for my Patients with …?

DOI: 10.3238/zfa.2017.0396–0401

Selbstevaluation als eine Frage der Professionalität

german translation / full article

Thomas Kühlein, Ana Carvalho, Catarina Viegas Dias, David Rodrigues, Daniel Pinto

Keywords: clinical governance electronic health record osteoporosis general practice

Self-Evaluation as a Question of Professionalism

Background: Physicians should want to know how they care for their patients. However, it will be unfamiliar for many to describe the quality of their work statistically. A basic question to ask would be: How do I care for my patients with a certain health condition? We wanted to find out whether we can answer this question for our patients suffering from osteoporosis by means of our electronic health record (EHR). The example of osteoporosis is chosen accidentally. Our intention is not to report a scientific study. Instead we want to call for a discussion of the topic of autonomous clinical governance in our practices which we perceive as an underdeveloped professional matter of course.

Methods: This report relates to an audit in the context of clinical governance. Postmenopausal women having experienced a fracture were identified from the EHR. At the same time, criteria to assess the quality of care were defined following current guidelines. As it emerged that the EHR was unsuitable to fulfill our purpose, the free software package “Epi Info 7” was used to create a template for data entry and analysis.

Results: Of the 41 female patients identified with possible osteoporotic fractures, as many as 90 % (37 patients) did not have any bone-density measurements recorded despite 39 % (16 patients) had been given a diagnosis of osteoporosis. Of the 16 patients with recorded osteoporosis, only two were prescribed antiosteoporotic medication. The EHR was largely inadequate to answer our question.

Conclusions: “How do I care for my patients with …?” is a difficult question to answer when relying on conventional EHR. The resulting answer is worrying and opens up a lot of room for improvement on behalf of our EHR and the quality of care we provide.

(State: 16.10.2017)

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