Couralet Melanie, Leleu Henri, Capuano Frederic, Marcotte Leah, Nitenberg Gérard, Sicotte Claude, Minvielle Etienne
INSERM U988, Institut Gustave Roussy, 38 rue Camille Desmoulins, Villejuif Cedex, France.
BMJ Qual Saf. 2013 Feb;22(2):155-62. doi: 10.1136/bmjqs-2012-001170. Epub 2012 Sep 26.
Developing quality indicators (QI) for national purposes (eg, public disclosure, paying-for-performance) highlights the need to find accessible and reliable data sources for collecting standardised data. The most accurate and reliable data source for collecting clinical and organisational information still remains the medical record. Data collection from electronic medical records (EMR) would be far less burdensome than from paper medical records (PMR). However, the development of EMRs is costly and has suffered from low rates of adoption and barriers of usability even in developed countries. Currently, methods for producing national QIs based on the medical record rely on manual extraction from PMRs. We propose and illustrate such a method. These QIs display feasibility, reliability and discriminative power, and can be used to compare hospitals. They have been implemented nationwide in France since 2006. The method used to develop these QIs could be adapted for use in large-scale programmes of hospital regulation in other, including developing, countries.
为国家目的（如公开披露、按绩效付费）制定质量指标（QI）凸显了寻找可获取且可靠的数据源以收集标准化数据的必要性。收集临床和组织信息最准确、可靠的数据源仍然是医疗记录。从电子病历（EMR）收集数据比从纸质病历（PMR）收集要轻松得多。然而，电子病历的开发成本高昂，即便在发达国家也存在采用率低和可用性障碍的问题。目前，基于医疗记录生成国家质量指标的方法依赖于从纸质病历中手动提取。我们提出并阐述了这样一种方法。这些质量指标显示出可行性、可靠性和鉴别力，可用于医院间的比较。自2006年起它们已在法国全国实施。用于制定这些质量指标的方法可加以调整，用于其他国家（包括发展中国家）的大规模医院监管项目。
