Long-term management of chronic obstructive pulmonary disease (COPD) in primary care depends on high quality clinical recording. From diagnosis to disease surveillance, it is difficult to assure high quality care of COPD without good records. For some years international evidence has exposed gaps between observed and recommended care in key quality indicators of COPD management including recording in the patient electronic health records (EHRs). This can be seen particularly in the recording and interpretation of spirometry measurements.^1–8 In their recent paper in this journal Heinmüller et al. have highlighted shortcomings in the recording of COPD care in general practices in Germany.⁹ Their findings suggest sub-optimal care across a range of quality indicators. Spirometry data to confirm a secure diagnosis of COPD could not be extracted. There was a lack of standardized recording within the EHRs. Data were not easily accessible from a single database and the records were difficult to search. It cannot be concluded that poor recording of quality indicators represents genuine deficits in care, but it begs the question whether low quality recording is itself evidence of low quality care.

中文翻译：

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聚焦 COPD 初级保健管理：电子健康记录

初级保健中慢性阻塞性肺疾病 (COPD) 的长期管理取决于高质量的临床记录。从诊断到疾病监测，如果没有良好的记录，就很难保证 COPD 的高质量护理。多年来，国际证据暴露了 COPD 管理的关键质量指标（包括记录在患者电子健康记录 (EHR) 中）观察和推荐护理之间的差距。这在肺活量测量的记录和解释中尤其可以看出。^1-8在他们最近发表在该期刊上的论文中，Heinmüller 等人。强调了德国一般实践中 COPD 护理记录的缺陷。⁹他们的研究结果表明，在一系列质量指标上都存在次优护理。无法提取用于确认 COPD 安全诊断的肺活量测定数据。EHR 中缺乏标准化的记录。从单一数据库中获取数据并不容易，而且记录搜索也很困难。不能断定质量指标记录不佳代表护理方面的真正缺陷，但它回避了低质量记录本身是否是低质量护理的证据的问题。