Huettig M, Buscher G, Puppe F, Buscher H-P
Clinic for Internal Medicine 2, DRK-Kliniken Berlin Köpenick.
Ultraschall Med. 2008 Jun;29(3):289-93. doi: 10.1055/s-2007-963306. Epub 2007 Dec 21.
Sonographic reports are examiner-dependent and may not always be reliable. We investigated concordance between documented findings and diagnostic conclusions--not the objective correctness of both--with the help of a knowledge-based documentation system.
The knowledge-based documentation system SonoConsult (SC) is routinely used in the ultrasound unit of a gastroenterological clinic for more than four years. Physicians documented findings with goal directed questionnaires, and diagnostic conclusions with free text. The consistency of documented findings and diagnoses was checked with the help of SC in a two-step process: 1. the diagnoses inferred by SC based on the documented findings were compared to the diagnoses of the physicians stated as free text. 2. In case of discrepancies, a more thorough comparison was performed manually by the medical authors of this study. For judging the practical relevance of discrepancies, diagnostic codes were pre-classified as a) being presumably of higher and lower relevance for the clinician and b) requiring simple or complex inference rules from the findings.
In a first series of 250 consecutive cases with 934 diagnoses (3.7 diagnoses per case), 71.1% showed agreement between diagnoses of the physicians and of SC and were judged as consistent compared to the documented findings. 24.4% of the diagnoses suggested by the documented findings, however, were not mentioned by the physicians (false negative) and 4.5% were mentioned by the physicians but not suggested by the documented findings (false positive). From the 24.4% missing diagnoses, 40% were pre-classified as being of higher relevance for the clinician. In a second series of 161 consecutive cases with 501 diagnoses (3.1 diagnoses per case), 61.1% were judged as consistent compared to the documented findings, 36.1% false negative and 2.8% false positive. In this study, we differentiated the missing diagnoses due to their inferential complexity: From the 152 complex diagnoses, 44% were missing, while from the 349 simple diagnoses, 32.7% were missing.
As shown for a sonographic department of a clinic of internal medicine, in sonographic reports, one has to be aware of discrepancies between question-set-based documentations of findings and diagnostic conclusions of the examiners. While a detailed documentation of findings is the basis of quality control, consistency checks between documented findings and diagnostic conclusions, which might be done automatically in an electronic patient record, would considerably improve the quality of the reports.
超声检查报告依赖于检查者，且并非总是可靠的。我们借助基于知识的文档系统，研究记录的检查结果与诊断结论之间的一致性——而非两者的客观正确性。
基于知识的文档系统SonoConsult（SC）在一家胃肠病诊所的超声科室已常规使用四年多。医生通过目标导向问卷记录检查结果，并用自由文本记录诊断结论。借助SC分两步检查记录的检查结果与诊断之间的一致性：1. 将SC根据记录的检查结果推断出的诊断与医生以自由文本形式给出的诊断进行比较。2. 如有差异，本研究的医学作者会手动进行更深入的比较。为判断差异的实际相关性，诊断代码被预先分类为：a）对临床医生可能具有较高或较低相关性；b）需要根据检查结果进行简单或复杂的推理规则。
在第一组连续250例病例共934个诊断（平均每例3.7个诊断）中，71.1%的病例显示医生与SC的诊断一致，与记录的检查结果相比被判定为一致。然而，记录的检查结果所提示的诊断中有24.4%未被医生提及（假阴性），4.5%被医生提及但未被记录的检查结果所提示（假阳性）。在24.4%未提及的诊断中，40%被预先分类为对临床医生具有较高相关性。在第二组连续161例病例共501个诊断（平均每例3.1个诊断）中，与记录的检查结果相比，61.1%被判定为一致，36.1%为假阴性，2.8%为假阳性。在本研究中，我们根据推理复杂性对未提及的诊断进行了区分：在152个复杂诊断中，44%未被提及，而在349个简单诊断中，32.7%未被提及。
如一家内科诊所的超声科室所示，在超声检查报告中，必须意识到基于问题集的检查结果记录与检查者诊断结论之间的差异。虽然详细记录检查结果是质量控制的基础，但记录的检查结果与诊断结论之间的一致性检查（可在电子病历中自动完成）将显著提高报告质量。
