Hammersley V S, Morris C J, Rodgers S, Cantrill J A, Avery A J
Division of Primary Care, University of Nottingham, Nottingham, UK.
J Clin Pharm Ther. 2006 Jun;31(3):223-9. doi: 10.1111/j.1365-2710.2006.00723.x.
Measuring and assessing the quality of health care services is an issue of high international importance. Providing data can be reliably extracted, making use of the electronic patient record (EPR) could help practitioners fulfil clinical governance obligations and ultimately improve the quality of patient care. The objective of this paper is to describe (i) the process used to apply a series of clinical indicators for preventable drug-related morbidity (PDRM) in the EPR, (ii) problems encountered and (iii) our attempts to resolve them.
The PDRM indicators were applied retrospectively in the EPR of all patients aged 18 years and over in nine general practices using the Morbidity Information and Query Export Syntax (MIQUEST) computer software programme.
Issues identified as requiring attention when attempting to extract data from the EPR include considering the ranges to be used for age and biochemical test results, accuracy of diagnosis and drug coding, the level of complexity of the information needed, and how best to manipulate the resulting data. Practical difficulties encountered were ensuring the query coding schemes were sufficiently robust and comprehensive to secure reliable data extraction, the number of MIQUEST queries required to express each indicator, the time-consuming nature of the stages involved in the data manipulation process.
Despite some practical difficulties, we have successfully used MIQUEST to identify potential preventable drug-related morbidities from the EPR. The quality of information that can be extracted from the EPR is obviously limited by the accuracy and completeness of the data on the system and the ability of the enquirer to reliably extract and manipulate that data.
Although some of the problems encountered were specific to the MIQUEST software, many, including considering appropriate ranges for age and biochemical test results and paying careful attention to the reliability of drug and diagnosis coding, are relevant whenever data are extracted from the EPR for any purpose.
衡量和评估医疗服务质量是一个具有高度国际重要性的问题。提供能够可靠提取的数据，利用电子病历（EPR）有助于从业者履行临床治理义务，并最终提高患者护理质量。本文的目的是描述（i）在电子病历中应用一系列可预防药物相关发病率（PDRM）临床指标的过程，（ii）遇到的问题，以及（iii）我们解决这些问题的尝试。
使用发病率信息与查询导出语法（MIQUEST）计算机软件程序，对九家全科诊所中所有18岁及以上患者的电子病历进行回顾性应用PDRM指标。
在尝试从电子病历中提取数据时，确定需要关注的问题包括考虑年龄和生化检测结果的取值范围、诊断和药物编码的准确性、所需信息的复杂程度，以及如何最好地处理所得数据。遇到的实际困难包括确保查询编码方案足够稳健和全面，以确保可靠的数据提取、表达每个指标所需的MIQUEST查询数量，以及数据处理过程中各个阶段的耗时性。
尽管存在一些实际困难，我们已成功使用MIQUEST从电子病历中识别出潜在的可预防药物相关发病率。从电子病历中可提取信息的质量显然受到系统数据准确性和完整性以及查询者可靠提取和处理该数据能力的限制。
虽然遇到的一些问题是MIQUEST软件特有的，但许多问题，包括考虑年龄和生化检测结果的适当取值范围以及仔细关注药物和诊断编码的可靠性，无论出于何种目的从电子病历中提取数据时都是相关的。
