Transhis : the Maltese experience with ICPC-2

Abstract

Since its formation in 1990, the Malta College of Family Doctors has strived to promote and improve the standard of Family Medicine practised in Malta. The concept of keeping good quality medical records is central to achieving this goal. A udit, essential for quality assurance, is almost impossible without medical records, and similarly research is also difficult without data from records to provide information about the population under study. It is not surprising then, that record-keeping was always considered important to allow development of Family Medicine as a discipline. Unfortunately, only a few doctors outside hospital regularly keep medical records. In the Government Health Centres, record keeping is very rudimentary, and has improved very little over the years. A minority of self-employed family doctors keep medical records, but most of those that do use a manual system of sorts, such as a card-file system. Such systems make data retrieval for analysis laborious, and also prone to errors. Recently, the availability of database development software has allowed solo practitioners to develop customised electronic medical record solutions. Furthermore, a handful of professional medical software packages have become available on the local market during the last few years. However, there is no standard for data storage and retrieval, and most of these programs are incompatible. In addition, there was no consensus about a classification system to use and most solutions do not incorporate an international classification to allow data to be summarised and analysed.