Over the past two decades, there has been a growing reliance on electronic health records (EHRs) to capture clinical data in general practice. However, in Australia, there is a lack of nationally agreed and implemented standards for EHRs, particularly in the following three areas:
- EHR structure, including linkages.
- Data element names and definitions
- Use of clinical terminology and classification
As a response to this, the issues brief describes four essential steps necessary to generate high-quality data from general practice EHRs:
- Establishing a defined EHR data model that interconnects related data elements.
- Ensuring consistent data element labels and definitions across EHRs
- Employing standardized clinical terminology and classifications
- Implementing accreditation processes for GP electronic health records.