Jones-Diette Julie, Robinson Natalie J, Cobb Malcolm, Brennan Marnie L, Dean Rachel S
Centre for Evidence-Based Veterinary Science, School of Veterinary Medicine & Science, University of Nottingham, Nottingham, LE 12 5RD, UK.
Deputy Head of School, School of Veterinary Medicine & Science, University of Nottingham, Nottingham, LE12 5RD, UK.
Prev Vet Med. 2017 Dec 1;148:121-126. doi: 10.1016/j.prevetmed.2016.11.014. Epub 2016 Nov 23.
The use of electronic patient records (EPRs) in veterinary research is becoming more common place. To date no-one has investigated how accurately and completely they represent the clinical interactions that happen between veterinary professionals, and their clients and patients. The aim of this study was to compare data extracted from consultations within EPRs with data gathered by direct observation of the same consultation. A secondary aim was to establish the inter-rater reliability of two researchers who examined the data extracted from the EPRs. A convenience sample of 36 small animal consultations undertaken by 2 veterinary surgeons (83% by one veterinary surgeon) at a mixed veterinary practice in the United Kingdom was studied. All 36 consultations were observed by a single researcher using a standardised data collection tool. The information recorded in the EPRs was extracted from the Practice Management Software (PMS) systems using a validated XML schema. The XML extracted data was then converted into the same format as the observed data by two independent researchers who examined the extracted information and recorded their findings using the same tool as for the observation. The issues discussed and any action taken relating to those problems recorded in the observed and extracted datasets were then compared. In addition the inter-rater reliability of the two researchers who examined the extracted data was assessed. Only 64.4% of the observed problems discussed during the consultations were recorded in the EPR. The type of problem, who raised the problem and at what point in the consultation the problem was raised significantly affected whether the problem was recorded or not in the EPR. Only 58.3% of observed actions taken during the consultations were recorded in the EPR and the type of action significantly affected whether it would be recorded or not. There was moderate agreement between the two researchers who examined the extracted data. This is the first study that examines how much of the activity that occurs in small animal consultations is recorded in the EPR. Understanding the completeness, reliability and validity of EPRs is vital if they are to continue to be used for clinical research and the results to direct clinical care.
电子病历（EPRs）在兽医研究中的应用正变得越来越普遍。迄今为止，还没有人研究过它们在多大程度上准确且完整地呈现了兽医专业人员与其客户及病患之间发生的临床互动。本研究的目的是将从电子病历中的会诊提取的数据与通过直接观察相同会诊收集的数据进行比较。第二个目的是确定两位研究人员检查从电子病历中提取的数据时的评分者间信度。在英国一家混合兽医诊所，对两位兽医外科医生进行的36例小动物会诊（其中83%由一位兽医外科医生进行）的便利样本进行了研究。由一名研究人员使用标准化数据收集工具观察了所有36例会诊。电子病历中记录的信息通过经过验证的XML模式从实践管理软件（PMS）系统中提取。然后，由两位独立研究人员将提取的XML数据转换为与观察数据相同的格式，这两位研究人员检查提取的信息，并使用与观察相同的工具记录他们的发现。然后比较观察到的和提取的数据集中讨论的问题以及针对这些问题采取的任何行动。此外，还评估了检查提取数据的两位研究人员的评分者间信度。会诊期间讨论的观察到的问题中，只有64.4%记录在电子病历中。问题的类型、提出问题的人以及在会诊的哪个阶段提出问题，对该问题是否记录在电子病历中有显著影响。会诊期间观察到的采取的行动中，只有58.3%记录在电子病历中，行动的类型对其是否会被记录有显著影响。检查提取数据的两位研究人员之间存在中等程度的一致性。这是第一项研究小动物会诊中发生的活动在电子病历中记录了多少的研究。如果要继续将电子病历用于临床研究并将结果用于指导临床护理，了解电子病历的完整性、可靠性和有效性至关重要。
