Aronsky D, Haug P J
Department of Medical Informatics, LDS Hospital, University of Utah, Salt Lake City 84143, USA.
J Am Med Inform Assoc. 2000 Jan-Feb;7(1):55-65. doi: 10.1136/jamia.2000.0070055.
This study examined whether clinical data routinely available in a computerized patient record (CPR) can be used to drive a complex guideline that supports physicians in real time and at the point of care in assessing the risk of mortality for patients with community-acquired pneumonia.
Emergency department of a tertiary-care hospital.
Retrospective analysis with medical chart review.
All 241 inpatients during a 17-month period (Jun 1995 to Nov 1996) who presented to the emergency department and had a primary discharge diagnosis of community-acquired pneumonia. METHODS/MAIN OUTCOME MEASURES: The 20 guideline variables were extracted from the CPR (HELP System) and the paper chart. The risk score and the risk class of the Pneumonia Severity Index were computed using data from the CPR alone and from a reference standard of all data available in the paper chart and the CPR at the time of the emergency department encounters. Availability and concordance were quantified to determine data quality. The type and cause of errors were analyzed depending on the source and format of the clinical variables.
Of the 20 guideline variables, 12 variables were required to be present for every computer-charted emergency department patient, seven variables were required for selected patients only, and one variable was not typically available in the HELP System during a patient's encounter. The risk class was identical for 86.7 percent of the patients. The majority of patients with different risk classes were assigned too low a risk class. The risk scores were identical for 72.1 percent of the patients. The average availability was 0.99 for the data elements that were required to be present and 0.79 for the data elements that were not required to be present. The average concordance was 0.98 when all a patient's variables were taken into account. The cause of error was attributed to the nurse charting in 77 percent of the cases and to the computerized evaluation in 23 percent. The type of error originated from the free-text fields in 64 percent, from coded fields in 21 percent, from vital signs in 14 percent, and from laboratory results in 1 percent.
From a clinical perspective, the current level of data quality in the HELP System supports the automation and the prospective evaluation of the Pneumonia Severity Index as a computerized decision support tool.
本研究旨在探讨计算机化患者记录（CPR）中常规可用的临床数据是否可用于驱动一个复杂的指南，该指南能在患者接受社区获得性肺炎治疗时，实时且在护理点为医生评估患者的死亡风险提供支持。
一家三级护理医院的急诊科。
通过病历回顾进行回顾性分析。
在17个月期间（1995年6月至1996年11月），所有241名到急诊科就诊且主要出院诊断为社区获得性肺炎的住院患者。
方法/主要观察指标：从CPR（HELP系统）和纸质病历中提取20项指南变量。仅使用CPR中的数据以及急诊科就诊时纸质病历和CPR中所有可用数据的参考标准来计算肺炎严重程度指数的风险评分和风险等级。对数据的可用性和一致性进行量化以确定数据质量。根据临床变量的来源和格式分析错误的类型和原因。
在20项指南变量中，每个计算机记录的急诊科患者需要存在12项变量，仅部分患者需要7项变量，且在患者就诊期间，HELP系统中通常没有1项变量。86.7%的患者风险等级相同。大多数不同风险等级的患者被分配的风险等级过低。72.1%的患者风险评分相同。对于需要存在的数据元素，平均可用性为0.99，对于不需要存在的数据元素，平均可用性为0.79。当考虑患者的所有变量时，平均一致性为0.98。77%的错误原因归因于护士记录，23%归因于计算机评估。错误类型64%源于自由文本字段，21%源于编码字段，14%源于生命体征，1%源于实验室结果。
从临床角度来看，HELP系统当前的数据质量水平支持将肺炎严重程度指数作为计算机化决策支持工具进行自动化和前瞻性评估。
