Eshel Ron, Bellolio Fernanda, Boggust Andy, Shapiro Nathan I, Mullan Aidan F, Heaton Heather A, Madsen Bo E, Homme James L, Iliff Benjamin W, Sunga Kharmene L, Wangsgard Cameron R, Vanmeter Derek, Cabrera Daniel
Department of Anesthesia, Critical Care and Pain, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States.
Am J Emerg Med. 2023 Jan;63:79-85. doi: 10.1016/j.ajem.2022.10.009. Epub 2022 Oct 13.
Medical encounters require an efficient and focused history of present illness (HPI) to create differential diagnoses and guide diagnostic testing and treatment. Our aim was to compare the HPI of notes created by an automated digital intake tool versus standard medical notes created by clinicians.
Prospective trial in a quaternary academic Emergency Department (ED). Notes were compared using the 5-point Physician Documentation Quality Instrument (PDQI-9) scale and the Centers for Medicare & Medicaid Services (CMS) level of complexity index. Reviewers were board certified emergency medicine physicians blinded to note origin. Reviewers received training and calibration prior to note assessments. A difference of 1 point was considered clinically significant. Analysis included McNemar's (binary), Wilcoxon-rank (Likert), and agreement with Cohen's Kappa.
A total of 148 ED medical encounters were charted by both digital note and standard clinical note. The ability to capture patient information was assessed through comparison of note content across paired charts (digital-standard note on the same patient), as well as scores given by the reviewers. Reviewer agreement was kappa 0.56 (CI 0.49-0.64), indicating moderate level of agreement between reviewers scoring the same patient chart. Considering all 18 questions across PDQI-9 and CMS scales, the average agreement between standard clinical note and digital note was 54.3% (IQR 44.4-66.7%). There was a moderate level of agreement between content of standard and digital notes (kappa 0.54, 95%CI 0.49-0.60). The quality of the digital note was within the 1 point clinically significant difference for all of the attributes, except for conciseness. Digital notes had a higher frequency of CMS severity elements identified.
Digitally generated clinical notes had moderate agreement compared to standard clinical notes and within the one point clinically significant difference except for the conciseness attribute. Digital notes more reliably documented billing components of severity. The use of automated notes should be further explored to evaluate its utility in facilitating documentation of patient encounters.
医疗问诊需要高效且有重点的现病史（HPI），以形成鉴别诊断并指导诊断性检查和治疗。我们的目的是比较自动数字录入工具生成的记录与临床医生创建的标准医疗记录中的HPI。
在一家四级学术急诊科（ED）进行前瞻性试验。使用5分制的医生记录质量工具（PDQI - 9）量表和医疗保险与医疗补助服务中心（CMS）的复杂程度指数对记录进行比较。评审人员为具有急诊医学专业认证的医生，他们对记录的来源不知情。在进行记录评估之前，评审人员接受了培训和校准。1分的差异被认为具有临床意义。分析包括McNemar检验（二元变量）、Wilcoxon秩和检验（Likert量表）以及Cohen's Kappa一致性分析。
通过数字记录和标准临床记录共记录了148例ED医疗问诊。通过比较配对病历（同一患者的数字记录 - 标准记录）中的记录内容以及评审人员给出的分数，评估获取患者信息的能力。评审人员的一致性为kappa 0.56（CI 0.49 - 0.64），表明对同一患者病历评分的评审人员之间存在中等程度的一致性。考虑PDQI - 9和CMS量表中的所有18个问题，标准临床记录和数字记录之间的平均一致性为54.3%（IQR 44.4 - 66.7%）。标准记录和数字记录的内容之间存在中等程度的一致性（kappa 0.54，95%CI 0.49 - 0.60）。除了简洁性之外，数字记录的质量在所有属性上都处于1分的临床显著差异范围内。数字记录识别出的CMS严重程度要素频率更高。
与标准临床记录相比，数字生成的临床记录具有中等程度的一致性，除简洁性属性外，在1分的临床显著差异范围内。数字记录更可靠地记录了严重程度的计费组成部分。应进一步探索使用自动记录，以评估其在促进患者问诊记录方面的效用。
