自由文本字段会改变编码数据的含义。
Free-text fields change the meaning of coded data.
作者信息
Hogan W R, Wagner M M
机构信息
Center for Biomedical Informatics University of Pittsburgh, USA.
出版信息
Proc AMIA Annu Fall Symp. 1996:517-21.
Abstract
Researchers have advocated the supplementation of coded fields with free-text fields in electronic medical records (EMRs) to provide clinicians with flexibility during data entry. They cite advantages of more complete data capture and improved clinician acceptance and use of the EMR. However, free text may have the disadvantage of changing the meaning of coded data, which causes lower data accuracy for applications that cannot read free text. We studied the free-text entries that clinicians made during the recording of medication data. We found that these entries changed the meaning of coded data and lowered data accuracy for the medical decision-support system (MDSS) in our EMR. We conclude that supplemental free-text entries made by clinicians frequently alter the meaning of coded data.
摘要
研究人员主张在电子病历（EMR）中用自由文本字段补充编码字段，以便临床医生在数据录入过程中具有灵活性。他们列举了能更完整地捕获数据以及提高临床医生对电子病历的接受度和使用率等优点。然而，自由文本可能存在改变编码数据含义的缺点，这会导致无法读取自由文本的应用程序的数据准确性降低。我们研究了临床医生在记录用药数据时所做的自由文本录入。我们发现这些录入改变了编码数据的含义，并降低了我们电子病历中医疗决策支持系统（MDSS）的数据准确性。我们得出结论，临床医生所做的补充自由文本录入经常会改变编码数据的含义。
相似文献
1
Free-text fields change the meaning of coded data.自由文本字段会改变编码数据的含义。
Proc AMIA Annu Fall Symp. 1996:517-21.
2
The accuracy of medication data in an outpatient electronic medical record.门诊电子病历中用药数据的准确性。
J Am Med Inform Assoc. 1996 May-Jun;3(3):234-44. doi: 10.1136/jamia.1996.96310637.
3
Creating and indexing teaching files from free-text patient reports.从自由文本患者报告中创建教学文件并建立索引。
Proc AMIA Symp. 1999:814-8.
4
Improving clinician acceptance and use of computerized documentation of coded diagnosis.提高临床医生对编码诊断计算机化文档的接受度和使用率。
Am J Manag Care. 1997 Apr;3(4):597-601.
5
Do you Read me?
Health Serv J. 1998 May 28;108(5606):suppl 8.
6
Evaluation of Meta-1 for a concept-based approach to the automated indexing and retrieval of bibliographic and full-text databases.Meta-1用于基于概念的书目数据库和全文数据库自动索引与检索方法的评估。
Med Decis Making. 1991 Oct-Dec;11(4 Suppl):S120-4.
7
Automating the assignment of diagnosis codes to patient encounters using example-based and machine learning techniques.使用基于示例和机器学习技术实现患者就诊诊断代码分配的自动化。
J Am Med Inform Assoc. 2006 Sep-Oct;13(5):516-25. doi: 10.1197/jamia.M2077. Epub 2006 Jun 23.
8
A controlled trial of automated classification of negation from clinical notes.一项关于临床记录中否定词自动分类的对照试验。
BMC Med Inform Decis Mak. 2005 May 5;5:13. doi: 10.1186/1472-6947-5-13.
9
Premillennial and postmillennial coding.千禧年前编码和千禧年后编码。
Top Health Inf Manage. 2000 Nov;21(2):81-4.
10
Automatic indexing of abstracts via natural-language processing using a simple thesaurus.
Med Decis Making. 1991 Oct-Dec;11(4 Suppl):S108-15.
引用本文的文献
1
Analyzing Patient-Provided Responses to Improve Collection of Health Equity Data Elements.分析患者提供的回复，以改进健康公平数据元素的收集。
AMIA Annu Symp Proc. 2024 Jan 11;2023:569-578. eCollection 2023.
2
Identification of Key Elements in Prostate Cancer for Ontology Building via a Multidisciplinary Consensus Agreement.通过多学科共识协议确定前列腺癌本体构建中的关键要素。
Cancers (Basel). 2023 Jun 8;15(12):3121. doi: 10.3390/cancers15123121.
3
Identifying Military Service Status in Electronic Healthcare Records from Psychiatric Secondary Healthcare Services: A Validation Exercise Using the Military Service Identification Tool.从精神科二级医疗服务的电子健康记录中识别兵役状态：使用兵役识别工具的验证实践
Healthcare (Basel). 2023 Feb 10;11(4):524. doi: 10.3390/healthcare11040524.
4
The use of narrative electronic prescribing instructions in pharmacoepidemiology: A scoping review for the International Society for Pharmacoepidemiology.叙述性电子处方说明在药物流行病学中的应用：国际药物流行病学学会的一项范围综述
Pharmacoepidemiol Drug Saf. 2021 Oct;30(10):1281-1292. doi: 10.1002/pds.5331. Epub 2021 Jul 28.
5
Towards augmenting structured EHR data: a comparison of manual chart review and patient self-report.迈向增强结构化电子健康记录数据：手工病历审查与患者自我报告的比较
AMIA Annu Symp Proc. 2020 Mar 4;2019:903-912. eCollection 2019.
6
Unlocking echocardiogram measurements for heart disease research through natural language processing.通过自然语言处理解锁用于心脏病研究的超声心动图测量方法。
BMC Cardiovasc Disord. 2017 Jun 12;17(1):151. doi: 10.1186/s12872-017-0580-8.
7
Methods and dimensions of electronic health record data quality assessment: enabling reuse for clinical research.电子健康记录数据质量评估的方法和维度：为临床研究提供可重用性。
J Am Med Inform Assoc. 2013 Jan 1;20(1):144-51. doi: 10.1136/amiajnl-2011-000681. Epub 2012 Jun 25.
8
Automatic electronic laboratory-based reporting of notifiable infectious diseases at a large health system.在一个大型医疗系统中基于实验室的法定传染病自动电子报告。
Emerg Infect Dis. 2002 Jul;8(7):685-91. doi: 10.3201/eid0807.010493.
9
Exploring the degree of concordance of coded and textual data in answering clinical queries from a clinical data repository.探索编码数据与文本数据在回答来自临床数据存储库的临床问题时的一致程度。
J Am Med Inform Assoc. 2000 Jan-Feb;7(1):42-54. doi: 10.1136/jamia.2000.0070042.
本文引用的文献
1
The accuracy of medication data in an outpatient electronic medical record.门诊电子病历中用药数据的准确性。
J Am Med Inform Assoc. 1996 May-Jun;3(3):234-44. doi: 10.1136/jamia.1996.96310637.
2
How useful is the UMLS metathesaurus in developing a controlled vocabulary for an automated problem list?统一医学语言系统元词表在为自动问题列表开发受控词汇表方面有多大用处？
Proc Annu Symp Comput Appl Med Care. 1993:705-9.
3
Automated linkage of free-text descriptions of patients with a practice guideline.将患者的自由文本描述与实践指南进行自动关联。
Proc Annu Symp Comput Appl Med Care. 1993:274-8.
4
A simple approach to physician entry of patient problem list.一种医生录入患者问题列表的简单方法。
Proc Annu Symp Comput Appl Med Care. 1994:206-10.
5
A comparison of four schemes for codification of problem lists.四种问题列表编码方案的比较。
Proc Annu Symp Comput Appl Med Care. 1994:201-5.
6
Acceptability of Unified Medical Language System terms as substitute for natural language general medicine clinic diagnoses.统一医学语言系统术语作为自然语言通用医学临床诊断替代词的可接受性。
Proc Annu Symp Comput Appl Med Care. 1994:193-7.
7
Coping with changing controlled vocabularies.应对不断变化的受控词汇表。
Proc Annu Symp Comput Appl Med Care. 1994:135-9.
8
Toward a medical-concept representation language. The Canon Group.迈向医学概念表示语言。佳能集团。
J Am Med Inform Assoc. 1994 May-Jun;1(3):207-17. doi: 10.1136/jamia.1994.95236153.
9
A general natural-language text processor for clinical radiology.一种用于临床放射学的通用自然语言文本处理器。
J Am Med Inform Assoc. 1994 Mar-Apr;1(2):161-74. doi: 10.1136/jamia.1994.95236146.
10
Natural language processing and the representation of clinical data.自然语言处理与临床数据的表示
J Am Med Inform Assoc. 1994 Mar-Apr;1(2):142-60. doi: 10.1136/jamia.1994.95236145.
Zotero 插件