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利用从全科医生电子病历中进行半自动数据提取的方式,收集基层医疗中处方开具质量的信息。

Collecting information on the quality of prescribing in primary care using semi-automatic data extraction from GPs' electronic medical records.

作者信息

Vandenberghe H E E, Van Casteren V, Jonckheer P, Bastiaens H, Van der Heyden J, Lafontaine M-F, De Clercq E

机构信息

Scientific Institute of Public Health, Unit of Epidemiology, J. Wytsmanstraat 14, 1050 Brussels, Belgium.

出版信息

Int J Med Inform. 2005 Jun;74(5):367-76. doi: 10.1016/j.ijmedinf.2005.02.004.

Abstract

OBJECTIVES

To evaluate a semi-automatic data extraction from the electronic medical record (EMR) of general practitioners (GPs) through a comparison with a paper sheets data collection simultaneously used in a primary care research project on the quality of prescribing for osteoarthritis in the elderly.

SUBJECTS

One hundred and fifty-two GPs using five different EMR-software systems participated with the semi-automatic data extraction from the EMR and 233 GPs collected data with paper registration sheets.

METHODS

The proportion of patients with respectively a drug prescription, paracetamol, a non-steroidal anti-inflammatory drug (NSAID) and ibuprofen were compared between the semi-automatic extraction and the paper data collection and among the EMR-software systems.

RESULTS

Using the semi-automatic data extraction, a significantly lower proportion of patients on drugs was obtained compared to the paper data collection (adjusted OR: 0.31; 95% CI 0.25-0.39). However, the proportion of patients on a specific type of drug was comparable. Within the results from the semi-automatic extraction, the results were heterogeneous among the different EMR-software systems.

CONCLUSIONS

The semi-automatic data extraction with multiple EMR-software systems proposed in this study seems suitable for quality of prescribing assessment in primary care. However, it may be less reliable when only a single EMR-software is used.

摘要

目的

通过与在一项关于老年人骨关节炎处方质量的初级保健研究项目中同时使用的纸质数据收集进行比较,评估从全科医生(GP)的电子病历(EMR)中进行半自动数据提取的情况。

研究对象

152名使用五种不同电子病历软件系统的全科医生参与了从电子病历中进行的半自动数据提取,233名全科医生使用纸质登记表收集数据。

方法

比较了半自动提取和纸质数据收集之间以及电子病历软件系统之间分别有药物处方、对乙酰氨基酚、非甾体抗炎药(NSAID)和布洛芬的患者比例。

结果

与纸质数据收集相比,使用半自动数据提取获得的用药患者比例显著更低(校正比值比:0.31;95%可信区间0.25 - 0.39)。然而,特定类型药物的患者比例相当。在半自动提取的结果中,不同电子病历软件系统的结果存在异质性。

结论

本研究中提出的使用多种电子病历软件系统进行半自动数据提取似乎适用于初级保健中的处方质量评估。然而,当仅使用单一电子病历软件时,其可靠性可能较低。

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