Svenson James E, Pollack Susan H, Fallat Mary E, Drapeau Jeanne L
Section of Emergency Medicine, University of Wisconsin, C7/379 CSC, 600 Highland Avenue, Madison, WI 53792, USA.
J Ky Med Assoc. 2003 Mar;101(3):109-12.
The purpose of this study was to assess the completeness and accuracy of information from two electronic datasets, one of which is voluntarily submitted, the other submitted by mandate.
Emergency department (ED) data have been voluntarily submitted by several hospitals to the Kentucky Emergency Medical Services Information System (KEMSIS). Similar information on all patients admitted to the hospital has been submitted by mandate to the state under the Uniform Billing Act (UB92). UB92 data for patients with at least one diagnosis code > or = 800 were available. The KEMSIS and UB 92 data for one hospital were compared to those manually abstracted from the ED log and medical records for completeness and accuracy.
There were 316 patients listed on the ED log that were subsequently admitted to the hospital. The KEMSIS database contained 266 (84%) of these records, but only 91 (34%) were classified as having been admitted. Of those correctly classified as admitted, only 25 (27%, or 9% of the total 266) were correctly classified as to the hospital of admission (directly to hospital or transferred to another facility). Discharge diagnoses in the KEMSIS database and hospital records were concordant in 240 (90%) of the patients, even for those misclassified as to disposition. There were 37 patients listed in the ED log admitted during the study period with at least one discharge diagnosis field > or = 800. Eight patients were transferred to another institution, making the total population available for study period 29. Only eight (28%) of these patients were included in the UB92 database. The diagnosis codes were concordant between the UB 92 data and ED log in all cases.
There is significant misclassification and/or omission in electronic databases. This is true regardless of whether data is reported voluntarily or by mandate. Electronic data must be independently validated before they are used for policy or research purposes.
本研究旨在评估两个电子数据集信息的完整性和准确性，其中一个是自愿提交的，另一个是按要求提交的。
几家医院已将急诊科（ED）数据自愿提交至肯塔基州紧急医疗服务信息系统（KEMSIS）。根据统一账单法案（UB92），医院所有入院患者的类似信息已按要求提交给该州。有至少一个诊断代码≥800的患者的UB92数据可用。将一家医院的KEMSIS和UB92数据与从ED日志和病历中手工提取的数据进行比较，以评估其完整性和准确性。
ED日志上列出的316名患者随后入院。KEMSIS数据库包含其中266条（84%）记录，但只有91条（34%）被归类为已入院。在那些被正确归类为已入院的记录中，只有25条（27%，占266条记录总数的9%）在入院医院（直接入院或转至其他机构）方面被正确归类。KEMSIS数据库中的出院诊断与医院记录在240名（90%）患者中一致，即使对于那些在处置方面分类错误的患者也是如此。在研究期间，ED日志上列出的有至少一个出院诊断字段≥800的入院患者有37名。8名患者转至其他机构，因此研究期间可供研究的患者总数为29名。这些患者中只有8名（28%）被纳入UB92数据库。在所有病例中，UB92数据和ED日志之间的诊断代码一致。
电子数据库中存在显著的错误分类和/或遗漏。无论数据是自愿报告还是按要求报告，都是如此。在将电子数据用于政策或研究目的之前，必须对其进行独立验证。
