Roukema Jolt, Los Renske K, Bleeker Sacha E, van Ginneken Astrid M, van der Lei Johan, Moll Henriette A
Department of Pediatrics, Sophia Children's Hospital, Rotterdam, The Netherlands.
Pediatrics. 2006 Jan;117(1):15-21. doi: 10.1542/peds.2004-2741.
Implementation of electronic medical record systems promises significant advances in patient care, because such systems enhance readability, availability, and data quality. Structured data entry (SDE) applications can prompt for completeness, provide greater accuracy and better ordering for searching and retrieval, and permit validity checks for data quality monitoring, research, and especially decision support. A generic SDE application (OpenSDE) to support documentation of patient history and physical examination findings was developed and tailored for the domain of general pediatrics.
To evaluate OpenSDE for its completeness, uniformity of reporting, and usability in general pediatrics.
Four (trainee) pediatricians documented data for 8 first-visit patients in the traditional, paper-based, medical record and immediately thereafter in OpenSDE (electronic record). The 32 paper records obtained served as the common data source for data entry in OpenSDE by the other 3 physicians (transcribed record). Data entered by 2 experienced users, with all patient information present in the paper record, served as the control record. Data entry times were recorded, and a questionnaire was used to assess users' experiences with OpenSDE.
Clinicians documented 44% of all available patient information identically in the paper and electronic records. Twenty-five percent of all patient information was documented only in the paper record, and 31% was present only in the electronic record. Differences were found in patient history and physical examination documentation in the electronic record; more information was missing for patient history (38%) than for physical examination (15%). Furthermore, physical examination contained more additional information (39%) than did patient history (21%). The interobserver agreement of documentation of patient information from the same data source was fair to moderate, with kappa values of 0.39 for patient history and 0.40 for physical examination. Data entry times in OpenSDE decreased from 25 minutes to <15 minutes, indicating a learning effect. The questionnaire revealed a positive attitude toward the use of OpenSDE in daily practice.
OpenSDE seems to be a promising application for the support of physician data entry in general pediatrics.
电子病历系统的实施有望在患者护理方面取得重大进展，因为此类系统提高了可读性、可用性和数据质量。结构化数据录入（SDE）应用程序可以促使信息完整，在搜索和检索方面提供更高的准确性和更好的排序，并允许对数据质量监测、研究尤其是决策支持进行有效性检查。开发了一种通用的SDE应用程序（OpenSDE）来支持患者病史和体格检查结果的记录，并针对普通儿科领域进行了定制。
评估OpenSDE在普通儿科中的完整性、报告的一致性和可用性。
四名（实习）儿科医生先以传统纸质病历记录8例初诊患者的数据，随后立即使用OpenSDE（电子病历）记录。获得的32份纸质病历作为另外3名医生在OpenSDE中进行数据录入的共同数据源（转录记录）。由2名经验丰富的用户录入的数据，纸质病历中包含所有患者信息，作为对照记录。记录数据录入时间，并使用问卷调查来评估用户使用OpenSDE的体验。
临床医生在纸质和电子病历中对所有可用患者信息的记录有44%是相同的。所有患者信息的25%仅记录在纸质病历中，31%仅存在于电子病历中。在电子病历中患者病史和体格检查记录存在差异；患者病史中缺失的信息（38%）比体格检查中（15%）更多。此外，体格检查包含的额外信息（39%）比患者病史（21%）更多。来自同一数据源的患者信息记录的观察者间一致性为中等，患者病史的kappa值为0.39，体格检查的kappa值为0.40。OpenSDE中的数据录入时间从25分钟减少到不到15分钟，表明存在学习效应。问卷调查显示对在日常实践中使用OpenSDE持积极态度。
OpenSDE似乎是支持普通儿科医生数据录入的一种有前景的应用程序。
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