Hawley Glenda, Jackson Claire, Hepworth Julie, Wilkinson Shelley A
APHCRI Centre of Research Excellence in Primary Health Care Microsystems, School of Medicine, Discipline of General Practice, University of Queensland, Level 8 Health Sciences Building, Building 16/910, Herston, Brisbane, QLD, 4029, Australia.
School of Public Health & Social Work, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD, 4059, Australia.
BMC Health Serv Res. 2014 Dec 21;14:650. doi: 10.1186/s12913-014-0650-x.
Historically, the paper hand-held record (PHR) has been used for sharing information between hospital clinicians, general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda, an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR.
We undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were compared for completeness of best practice variables collected The primary outcome was the presence of best practice variables and the secondary outcomes were the differences in individual variables between the records.
Ninety-four percent of paper medical charts were available in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR, compared with the PHR, were urine culture, glucose tolerance test, nuchal screening, morphology scans, folic acid advice, tobacco smoking, illicit drug assessment and domestic violence assessment (p = 0.001). Additionally the documentation of immunisations (pertussis, hepatitis B, varicella, fluvax) were markedly improved in the EHR (p = 0.001). The variables of blood pressure, proteinuria, blood group, antibody, rubella and syphilis status, showed no significant differences in completeness of recording.
This is the first paper to report on the comparison of clinical data collected on a PHR and EHR in a maternity shared-care setting. The use of an EHR demonstrated significant improvements to the collection of best practice variables. Additionally, the data in an EHR were more available to relevant clinical staff with the appropriate log-in and more easily retrieved than from the PHR. This study contributes to an under-researched area of determining data quality collected in patient records.
从历史上看，纸质手持记录（PHR）一直用于在产科共享护理环境中，供医院临床医生、全科医生和孕妇之间共享信息。最近，为了与国家电子健康议程保持一致，澳大利亚一家三级产科服务机构引入了电子健康记录（EHR），以取代用于数据收集和传输的PHR。本研究的目的是检查和比较PHR和EHR中收集的临床数据的完整性。
我们进行了一项比较队列设计研究，以确定两个阶段从产科记录中收集的数据在完整性上的差异。第一阶段的数据从PHR中收集，第二阶段的数据从EHR中收集。比较记录中收集的最佳实践变量的完整性。主要结果是最佳实践变量的存在情况，次要结果是记录之间各个变量的差异。
第一阶段94%的纸质病历可用，第二阶段产科数据库中100%的记录可用。没有PHR或EHR拥有完整的最佳实践变量数据集。与PHR相比，EHR中记录的数据完整性有显著改善的变量有尿培养、葡萄糖耐量试验、颈部筛查、形态学扫描、叶酸建议、吸烟、非法药物评估和家庭暴力评估（p = 0.001）。此外，EHR中免疫接种（百日咳、乙肝、水痘、流感疫苗）的记录有显著改善（p = 0.001）。血压、蛋白尿、血型、抗体、风疹和梅毒状态等变量在记录完整性方面没有显著差异。
这是第一篇报告在产科共享护理环境中，对PHR和EHR收集的临床数据进行比较的论文。使用EHR显示出在收集最佳实践变量方面有显著改进。此外，具有适当登录权限的相关临床工作人员可以更方便地从EHR中获取数据，并且比从PHR中检索数据更容易。本研究为确定患者记录中收集的数据质量这一研究较少的领域做出了贡献。
