Comparison of computer-aided and human review of general practitioners' management of hypertension.

Computer programs that automatically review decisions can help physicians provide better patient care. In the Netherlands, the ELIAS computer information system has replaced paper medical records in some general practices. We have written a computer program called 'HyperCritic' that audits general practitioners' management of patients with essential hypertension by taking patient-specific data from the ELIAS system. We investigated whether the computer-based medical records contain sufficient information to generate critiques, and compared the limitations of audit by hypercritic with those of review by a panel of eight physicians. Hypercritic and the physicians independently reviewed the medical records of 20 randomly selected patients with hypertension and commented on the decisions made at each of 243 patient visits. Of 468 comments on patient management, 260 were judged correct by six or more of the physicians; hypercritic also made 118 of these 260 comments. The main reasons why the program did not produce the other 142 comments were: insufficient data in the computer-based medical record; absence of sufficient medical consensus; and omissions in the database of hypercritic. Calculation of an "index of merit" ([sensitivity + specificity] - 1) for individual reviewers showed that hypercritic performed better (index of merit 0.62) in its limited domain than did physician reviewers (0.3-0.56). At least in hypertension management, automated review of computer-based medical records compares favourably with review by physicians. Further development of computer-aided clinical audit requires the introduction of computer-based medical records that capture the reasoning of physicians, and of widely accepted practice guidelines.