Medical audit based on computer-stored patient records exemplified with an audit of hypertension care

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Abstract
Objective - To audit hypertension care at a health centre using computer-based patient records as the source of information and a query language as the analysis tool. Design - Retrospective database study comparing hypertension care in 1989 with hypertension care in 1990. Setting - One health centre in Sweden with six general practitioners and two doctors on vocational training. Participants - All patients with hypertension in 1989 and 1990. Main outcome measure - The percentage of records that complied with the criteria in the hypertension care protocol. Results - 585 records in 1989 and 574 records in 1990 were reviewed automatically by a series of 30 database queries. The computer time needed for the review was eight hours. The first audit showed deficiencies in the management of hypertension, in particular concerning patient history taking and risk factor analysis. The second audit, after the introduction of the hypertension care protocol, showed some minor improvements in the recording and also an increased rate of well treated hypertensive patients. Conclusion - Computer-based patient records may facilitate the review of medical records that is needed in medical audit. The audit demonstrates the gap between optimal care and clinical reality.