Barrie J L, Marsh D R
University of Manchester.
BMJ. 1992 Jan 18;304(6820):159-62. doi: 10.1136/bmj.304.6820.159.
To determine the completeness and accuracy of data in a computerised clinical information system (Manchester orthopaedic database) in comparison with the data available through the Hospital Activity Analysis.
Retrospective review of case notes, computer data, and Hospital Activity Analysis data.
Orthopaedic unit in a district general hospital in Manchester.
200 random patient records distributed through the period of use of the computer system (1 October 1988 to 31 March 1990) and 121 records for random admissions between 1 April 1989 and 31 March 1990, 71 of which were included in the previous sample.
Conformity of the computer record key words and Hospital Activity Analysis codes to an ideal key word record and ideal code record drawn up by one investigator from the clinical notes; overall quality (completeness times accuracy).
Overall completeness of the data in the orthopaedic database was 62% and the accuracy was 96%. Completeness improved after feedback to doctors on the use of key words in regular audit meetings. Completeness was higher in inpatient than outpatient records (69.9% v 53.7%, p less than 0.001) and when a new key word was required compared with missing and incorrect key words (both p less than 0.001). Completeness was lower when the key word was required of a senior registrar (p less than 0.05). Accuracy was not significantly different. The completeness of Hospital Activity Analysis data was 90.5% and accuracy 69.5%. Thus the overall data quality was similar in both systems.
Even in a system designed for simple and efficient data capture, compliance by users was poor. Accuracy was high, suggesting that users understood the principles of data entry. Completeness of data capture can be improved by providing feedback to users on use of the system and performance. Improvements in future versions of the software should improve performance.
与通过医院活动分析获得的数据相比，确定计算机化临床信息系统（曼彻斯特骨科数据库）中数据的完整性和准确性。
对病历、计算机数据和医院活动分析数据进行回顾性审查。
曼彻斯特一家区综合医院的骨科病房。
在计算机系统使用期间（1988年10月1日至1990年3月31日）随机抽取的200份患者记录，以及1989年4月1日至1990年3月31日期间随机入院的121份记录，其中71份包含在先前的样本中。
计算机记录关键词和医院活动分析编码与一名研究者根据临床记录制定的理想关键词记录和理想编码记录的一致性；整体质量（完整性乘以准确性）。
骨科数据库中数据的整体完整性为62%，准确性为96%。在定期审核会议上向医生反馈关键词的使用情况后，完整性有所提高。住院患者记录的完整性高于门诊患者记录（69.9%对53.7%，p<0.001），需要新关键词时的完整性高于缺失和错误关键词时的完整性（p均<0.001）。当要求高级住院医师填写关键词时，完整性较低（p<0.05）。准确性无显著差异。医院活动分析数据的完整性为90.5%，准确性为69.5%。因此，两个系统的整体数据质量相似。
即使在一个旨在简单高效采集数据的系统中，用户的依从性也很差。准确性很高，表明用户理解数据录入的原则。通过向用户反馈系统使用情况和性能，可以提高数据采集的完整性。软件未来版本的改进应能提高性能。
