Mullin Sarah, Anand Edwin, Sinha Shyamashree, Song Buer, Zhao Jane, Elkin Peter L
Department of Biomedical Informatics, University at Buffalo, Buffalo, NY, USA.
Stud Health Technol Inform. 2017;241:165-172.
In a retrospective secondary-use EHR study identifying a cohort of Non-Valvular Atrial Fibrillation (NVAF) patients, chart abstraction was done by two sets of clinicians to create a gold standard for risk measures CHA2DS2-VASc and HAS-BLED. Inter-rater reliability between each set of clinicians for NVAF and the outcomes of interest were variable, ranging from extremely low agreement to high agreement. To assess the chart abstraction process, a focus group and a survey was conducted. Survey findings revealed patterns of difficulty in assessing certain items dealing with temporality and social data. The focus group raised issues on the quality and completeness of EHR data, including missing encounters, truncated notes, and low granularity. It also raised the issue of the usability of the data system, the Clinical Data Viewer, which did not mirror a live EHR and made it difficult to record outcomes. Finally, the focus group found it was difficult to infer certain outcomes, like severity, from the provided data. These factors produced differences in clinician rated outcomes.
在一项回顾性二次使用电子健康记录（EHR）研究中，该研究确定了一组非瓣膜性心房颤动（NVAF）患者，两组临床医生进行了病历摘要提取，以创建风险评估指标CHA2DS2-VASc和HAS-BLED的金标准。每组临床医生之间关于NVAF及感兴趣结局的评分者间信度各不相同，从极低一致性到高一致性不等。为评估病历摘要提取过程，开展了一次焦点小组讨论和一项调查。调查结果揭示了在评估某些涉及时间性和社会数据的项目时存在困难的模式。焦点小组提出了有关EHR数据质量和完整性的问题，包括就诊缺失、记录不完整以及低粒度。它还提出了数据系统Clinical Data Viewer的可用性问题，该系统无法反映实时EHR，使得记录结局变得困难。最后，焦点小组发现从所提供的数据中推断某些结局（如严重程度）很困难。这些因素导致了临床医生对结局的评分存在差异。
