Berner Eta S, Kasiraman Ramkumar K, Yu Feliciano, Ray Midge N, Houston Thomas K
University of Alabama at Birmingham, AL, USA.
AMIA Annu Symp Proc. 2005;2005:41-5.
Clinical decision support system (CDSS) performance may vary with the quality of the input data. We assessed the impact of medical record completeness and accuracy on a CDSS that provides risk assessment for gastrointestinal bleeding and recommends therapy when prescribing NSAIDs. We examined the documentation of six data elements in the medical record and the impact on the performance of the CDSS. We reviewed 178 transcribed clinical encounters from standardized patients with predefined clinical histories. Results showed that the mean completeness score across all encounters was .34. The mean correctness score for those elements present was .94. When the available data was input into the CDSS, the missing data elements resulted in inappropriate and unsafe recommendations in almost 77% of the encounters. The results show that important gaps in the medical record can affect the accuracy of a CDSS designed to improve safe prescribing.
临床决策支持系统（CDSS）的性能可能会因输入数据的质量而有所不同。我们评估了病历完整性和准确性对一个为胃肠道出血提供风险评估并在开具非甾体抗炎药（NSAIDs）时推荐治疗方案的CDSS的影响。我们检查了病历中六个数据元素的记录情况以及对CDSS性能的影响。我们回顾了178例来自具有预定义临床病史的标准化患者的转录临床会诊记录。结果显示，所有会诊记录的平均完整性得分为0.34。存在的那些元素的平均正确性得分为0.94。当将可用数据输入CDSS时，在几乎77%的会诊记录中，缺失的数据元素导致了不恰当和不安全的建议。结果表明，病历中的重要空白可能会影响旨在改善安全用药的CDSS的准确性。
