Jenders R A, Dasgupta B, Mercedes D, Fries F, Stambaugh K
Department of Medical Informatics, Columbia University, New York, New York, USA.
Proc AMIA Symp. 1999:286-90.
An ongoing challenge in the creation of clinical information systems is the capture of structured clinical information from health care providers while avoiding duplicate data recording. Because immunizations are reimbursable medical procedures, practice management systems that already capture such procedures may be used as a source of clinical data for information systems. We instituted a method for capturing such data on one campus of a multi-institution pediatric immunization registry. We measured the effectiveness of this capture by comparing it to manual audits of selected paper charts over 26 months. Of the immunizations documented by chart audit, 39.69% were captured by the practice management system. Of those not captured, we estimate that a substantial portion were immunizations administered elsewhere and as a result not submitted as a claim through the practice management system. In turn, this was affected by a rate of patient disengagement from primary care of 49%. We discuss the issues associated with using claims data to capture clinical information in the setting of an immunization registry and review possible explanations for this data capture rate.
创建临床信息系统时面临的一个持续挑战是在避免重复数据记录的同时，从医疗保健提供者那里获取结构化的临床信息。由于免疫接种是可报销的医疗程序，已经记录此类程序的实践管理系统可用作信息系统的临床数据来源。我们在一个多机构儿科免疫接种登记处的一个校区建立了一种获取此类数据的方法。我们通过将其与26个月内对选定纸质病历的人工审核进行比较，来衡量这种数据获取的有效性。在通过病历审核记录的免疫接种中，39.69%是由实践管理系统获取的。在未被获取的免疫接种中，我们估计很大一部分是在其他地方进行的免疫接种，因此没有通过实践管理系统提交索赔。反过来，这又受到49%的患者脱离初级保健率的影响。我们讨论了在免疫接种登记处使用索赔数据来获取临床信息相关的问题，并审查了这种数据获取率的可能解释。
