验证和衡量计算机化医疗服务提供者文档质量的初步步骤。
Initial Steps toward Validating and Measuring the Quality of Computerized Provider Documentation.
作者信息
Hammond Kenric W, Efthimiadis Efthimis N, Weir Charlene R, Embi Peter J, Thielke Stephen M, Laundry Ryan M, Hedeen Ashley
机构信息
VA Puget Sound Health Care System, Seattle WA;
出版信息
AMIA Annu Symp Proc. 2010 Nov 13;2010:271-5.
BACKGROUND
Concerns exist about the quality of electronic health care documentation. Prior studies have focused on physicians. This investigation studied document quality perceptions of practitioners (including physicians), nurses and administrative staff.
METHODS
An instrument developed from staff interviews and literature sources was administered to 110 practitioners, nurses and administrative staff. Short, long and original versions of records were rated.
RESULTS
Length transformation did not affect quality ratings. On several scales practitioners rated notes less favorably than administrators or nurses. The original source document was associated with the quality rating, as was tf·idf, a relevance statistic computed from document text. Tf·idf was strongly associated with practitioner quality ratings.
CONCLUSION
Document quality estimates were not sensitive to modifying redundancy in documents. Some perceptions of quality differ by role. Intrinsic document properties are associated with staff judgments of document quality. For practitioners, the tf·idf statistic was strongly associated with the quality dimensions evaluated.
背景
人们对电子医疗记录的质量存在担忧。先前的研究主要集中在医生身上。本调查研究了从业者（包括医生）、护士和行政人员对文档质量的看法。
方法
通过员工访谈和文献资料开发的一份调查问卷被发放给110名从业者、护士和行政人员。对简短、冗长和原始版本的记录进行了评分。
结果
篇幅的变化不影响质量评分。在几个量表上，从业者对记录的评价不如管理人员或护士有利。原始源文档与质量评分相关，词频逆文档频率（tf·idf）也与质量评分相关，tf·idf是根据文档文本计算出的一个相关性统计量。tf·idf与从业者的质量评分密切相关。
结论
文档质量评估对修改文档冗余不敏感。不同角色对质量的一些看法存在差异。文档的内在属性与员工对文档质量的判断相关。对于从业者来说，tf·idf统计量与所评估的质量维度密切相关。
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