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新南威尔士大学基于实践的电子研究网络:疾病登记、数据质量与效用。

The University of NSW electronic practice based research network: disease registers, data quality and utility.

作者信息

Taggart J, Liaw S T, Dennis S, Yu H, Rahimi A, Jalaludin B, Harris M

机构信息

University of NSW Centre for Primary Health Care and Equity, Iran.

出版信息

Stud Health Technol Inform. 2012;178:219-27.

PMID:22797045
Abstract

INTRODUCTION

Accurate well-maintained registers are a prerequisite to co-ordinated care of patients with chronic diseases. Their effectiveness in enabling improved management is dependent on the quality of the information captured. This paper provides an overview into the methodology and data quality of the electronic Practice Based Research Network.

METHODS

Clinical records with no identifying information are routinely extracted from four general practices. The data are linked in the data warehouse. Data quality is assessed for completeness, correctness and consistency. Reports on data quality are given back to practices and semi-structured interviews provide information to interpret the results and discuss how data quality could be improved.

FINDINGS

Data quality is mostly complete for sex and date of birth but indigenous status, smoking and weight were incomplete. There are generally high levels of correctness and internal consistency. Completeness of records in assisting the management of diabetes patients using the annual cycle of care was poor. GPs often use the progress notes to enter information during the consultation and coding diagnoses was considered onerous.

DISCUSSION

The routine capture of electronic clinical health records from primary health care and health services can be used to monitor performance and improve the quality of clinical records. There is a need for accurate and comprehensive clinical records to ensure the safety and quality of clinical practice. Understanding the true reasons for poor data quality is complex. Having a community-based research network may assist in answering some of these questions.

CONCLUSION

Electronic health records are increasingly being used for secondary research and evaluation, beyond the primary purpose of supporting clinical care. The data must be of sufficient quality to support these purposes.

摘要

引言

准确且维护良好的登记册是对慢性病患者进行协调护理的前提条件。其在实现更好管理方面的有效性取决于所采集信息的质量。本文概述了基于实践的电子研究网络的方法和数据质量。

方法

从四个全科诊所定期提取无身份识别信息的临床记录。数据在数据仓库中进行关联。对数据质量的完整性、正确性和一致性进行评估。将数据质量报告反馈给诊所,通过半结构化访谈提供信息以解读结果并讨论如何提高数据质量。

研究结果

性别和出生日期的数据质量大多完整,但原住民身份、吸烟情况和体重数据不完整。总体而言,正确性和内部一致性水平较高。在使用年度护理周期协助糖尿病患者管理方面,记录的完整性较差。全科医生在会诊期间常使用病程记录来录入信息,且编码诊断被认为很繁琐。

讨论

从初级卫生保健和卫生服务机构常规采集电子临床健康记录可用于监测绩效并提高临床记录质量。需要准确和全面的临床记录以确保临床实践的安全性和质量。理解数据质量差的真正原因很复杂。拥有一个基于社区的研究网络可能有助于回答其中一些问题。

结论

电子健康记录越来越多地用于二级研究和评估,超出了支持临床护理的主要目的。数据必须具备足够的质量以支持这些目的。

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