Orthopedics. 2020 Sep 1;43(5):e404-e408. doi: 10.3928/01477447-20200619-10. Epub 2020 Jul 7.
Electronic health record (EHR) technologies have improved the ease of access to structured clinical data. The standard means by which data are collected continues to be manual chart review. The authors compared the accuracy of manual chart review against modern electronic data warehouse queries. A manual chart review of the EHR was performed with medical record numbers and surgical admission dates for the 100 most recent inpatient venous thromboembolic events after total joint arthroplasty. A separate data query was performed with the authors' electronic data warehouse. Data sets were then algorithmically compared to check for matches. Discrepancies between data sets were evaluated to categorize errors as random vs systematic. From 100 unique patient encounters, 27 variables were retrieved. The average transcription error rate was 9.19% (SD, ±5.74%) per patient encounter and 11.04% (SD, ±21.40%) per data variable. The systematic error rate was 7.41% (2 of 27). When systematic errors were excluded, the random error rate was 5.79% (SD, ±7.04%) per patient encounter and 5.44% (SD, ±5.63%) per data variable. Total time and average time for manual data collection per patient were 915 minutes and 10.3±3.89 minutes, respectively. Data collection time for the entire electronic query was 58 seconds. With an error rate of 10%, manual chart review studies may be more prone to type I and II errors. Computer-based data queries can improve the speed, reliability, reproducibility, and scalability of data retrieval and allow hospitals to make more data-driven decisions. [Orthopedics. 2020;43(5):e404-e408.].
电子健康记录 (EHR) 技术提高了获取结构化临床数据的便捷性。数据采集的标准手段仍然是手动图表审查。作者比较了手动图表审查与现代电子数据仓库查询的准确性。通过医疗记录号码和外科住院日期,对最近 100 例全膝关节置换术后静脉血栓栓塞事件的电子病历进行了手动图表审查。使用作者的电子数据仓库进行了单独的数据查询。然后通过算法比较数据集以检查匹配项。评估数据集之间的差异,以将错误分类为随机错误与系统错误。从 100 个独特的患者就诊中,检索到 27 个变量。每个患者就诊的平均转录错误率为 9.19%(标准差,±5.74%),每个数据变量的错误率为 11.04%(标准差,±21.40%)。系统错误率为 7.41%(27 个变量中有 2 个)。当排除系统错误时,随机错误率为每个患者就诊 5.79%(标准差,±7.04%),每个数据变量的错误率为 5.44%(标准差,±5.63%)。手动数据采集每个患者的总时间和平均时间分别为 915 分钟和 10.3±3.89 分钟。整个电子查询的采集时间为 58 秒。错误率为 10%时,手动图表审查研究可能更容易发生 I 型和 II 型错误。基于计算机的数据查询可以提高数据检索的速度、可靠性、可重复性和可扩展性,并使医院能够做出更多的数据驱动决策。[骨科。2020;43(5):e404-e408.]。