Developing National Minimum Data Set for Primary Health Care Record in Iran

Background: The health information system is an essential part of the health system and has a vital role in increasing the efficiency and effectiveness of the health system, especially in primary health care (PHC). This study was conducted to determine the minimum data set required in the electronic health record (EHR) for primary health care (PHC) in the health system of Iran as an example of a low-middle-income country. Methods: This study is a combination of qualitative and quantitative methods conducted from 2021 to 2022, and includes three main stages, reviewing the theoretical foundations of research and designing the main framework of interview guide questions, a qualitative study through an interview with 42 managers of the health system at the national level to determine the minimum data in the electronic health, and determine the validity of the data via Delphi method using SPSS software, version 15. Results: After reviewing the minimal data set in EHR in seven selected countries, and during the interviews conducted with specialists, 7 main concepts and 5 sub-concepts were extracted from the interviews. Based on this, 159 information elements were included in the survey, and in two Delphi rounds, 145 information elements in seven sections of children, mothers, mental health, elderly, para-clinic, medicine, and vaccination were agreed upon by the experts. Conclusion: To standardize the data structure, it is necessary to create a database of national health information in the country’s EHR. The existence of a standard minimum data set can lead to the access of accurate and unambiguous information to the service recipient. It is essential to pay more attention to mental health programs and the elderly and use the latest information in the design of the minimum data set in the health system.