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计算机化数据收集:选定的普通医疗实践中的实用性和质量

Computerised data collection: practicability and quality in selected general practices.

作者信息

Hobbs F D, Hawker A

机构信息

Department of General Practice, University of Birmingham, Edgbaston, UK.

出版信息

Fam Pract. 1995 Jun;12(2):221-6. doi: 10.1093/fampra/12.2.221.

Abstract

The objective of the study as to assess the consistency with which a set of pre-defined data about three fictitious patients was entered into a sample group of practice computer systems, and to measure the time required for routine data capture of this kind. The study design was a prospective, piloted, postal survey, in which respondents were requested to enter a variety of general sample data onto their systems, to time the process, and record details of any difficulties. The subjects were 76 (39%) responding general practices in England and Ulster, from a random sample of members of a GP computer specialist group. These results (which in view of the highly motivated characteristics of the responding sample are likely to represent best practice) showed that differing conventions were applied in entering patient data, even among practices using the same type of computer system. Potentially significant errors and distortions were found in the data as recorded in the systems, such as the 29% of immunisation sequences which were slightly inaccurately entered. The main problems with the data entry comprised simple operator errors, inconsistency in the use of terms entered, and difficulties in recording negative data (only 20% of practices could enter patient 'not incontinent'). Practices varied widely in the way they allocated data recording responsibilities to staff, with only 6% of practices involving all staff in data entry.(ABSTRACT TRUNCATED AT 250 WORDS)

摘要

该研究的目的是评估关于三名虚拟患者的一组预定义数据录入到一组实践计算机系统中的一致性,并测量此类常规数据采集所需的时间。研究设计为一项前瞻性、试点性的邮寄调查,要求受访者在其系统上录入各种一般样本数据,记录该过程的时间,并记录遇到的任何困难的细节。研究对象是来自全科医生计算机专家小组随机抽取的英格兰和阿尔斯特的76家(39%)做出回应的全科诊所。这些结果(鉴于做出回应的样本具有高度积极性的特点,可能代表了最佳实践)表明,即使在使用同一类型计算机系统的诊所中,录入患者数据时也采用了不同的惯例。在系统记录的数据中发现了潜在的重大错误和偏差,例如29%的免疫接种顺序录入略有不准确。数据录入的主要问题包括简单的操作员错误、录入术语使用的不一致以及记录阴性数据的困难(只有20%的诊所能够录入患者“无大小便失禁”)。诊所在将数据记录职责分配给工作人员的方式上差异很大,只有6%的诊所让所有工作人员参与数据录入。(摘要截选于250字)

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