Brown Philip J B, Warmington Victoria
St Thomas' Hospital, London, UK.
Int J Med Inform. 2002 Dec 18;68(1-3):91-8. doi: 10.1016/s1386-5056(02)00068-0.
Increasing reliance is being placed on electronic medical records to support clinical care and achieve improved quality standards. In order for clinical information systems (CIS) to deliver excellence the data within it needs to be complete, consistent and accurate. This capture of data is critical but forms only part of the procedure in delivering quality health care during the clinician-patient encounter. A number of processes are involved in this encounter, each of which has to be performed flawlessly to deliver a perfect outcome. This paper outlines a method of assessing the quality of these processes involved in healthcare provision and data quality within a CIS. It proposes the principle of Data Quality Probes (DQP) to assess the performance of the whole encounter system. The main feature of this is the generation of a query which clinical knowledge predicts should not retrieve any cases in a system performing flawlessly. Any cases retrieved (which fail the DQP) indicate an error in either data quality or clinical judgment. This approach is applied practically within the paradigm of a UK family practice testing the hypothesis that a series DQPs can provide a valuable method for monitoring both the data accuracy of a CIS and the provision of quality patient care.
人们越来越依赖电子病历以支持临床护理并实现更高的质量标准。为了使临床信息系统（CIS）表现卓越，其中的数据需要完整、一致且准确。数据的获取至关重要，但这只是在医患互动过程中提供高质量医疗服务程序的一部分。这种互动涉及多个流程，每个流程都必须完美执行才能产生理想的结果。本文概述了一种评估医疗保健提供过程中这些流程的质量以及CIS中数据质量的方法。它提出了数据质量探针（DQP）原则来评估整个互动系统的性能。其主要特点是生成一个查询，临床知识预测在完美运行的系统中不应检索到任何病例。任何检索到的病例（未通过DQP）都表明数据质量或临床判断存在错误。这种方法在英国家庭医疗的范例中实际应用，检验了一系列DQP可以为监测CIS的数据准确性和提供高质量患者护理提供有价值方法的假设。
