Hogan W R, Wagner M M
Center for Biomedical Informatics, University of Pittsburgh, PA, USA. wrh3+@pitt.edu
J Am Med Inform Assoc. 1997 Sep-Oct;4(5):342-55. doi: 10.1136/jamia.1997.0040342.
Data in computer-based patient records (CPRs) have many uses beyond their primary role in patient care, including research and health-system management. Although the accuracy of CPR data directly affects these applications, there has been only sporadic interest in, and no previous review of, data accuracy in CPRs. This paper reviews the published studies of data accuracy in CPRs. These studies report highly variable levels of accuracy. This variability stems from differences in study design, in types of data studied, and in the CPRs themselves. These differences confound interpretation of this literature. We conclude that our knowledge of data accuracy in CPRs is not commensurate with its importance and further studies are needed. We propose methodological guidelines for studying accuracy that address shortcomings of the current literature. As CPR data are used increasingly for research, methods used in research databases to continuously monitor and improve accuracy should be applied to CPRs.
基于计算机的患者记录（CPR）中的数据除了在患者护理中发挥主要作用外，还有许多其他用途，包括研究和卫生系统管理。尽管CPR数据的准确性直接影响这些应用，但人们对CPR数据准确性的关注只是零星的，之前也没有对其进行过综述。本文回顾了已发表的关于CPR数据准确性的研究。这些研究报告的准确性水平差异很大。这种变异性源于研究设计、所研究数据类型以及CPR本身的差异。这些差异混淆了对该文献的解读。我们得出结论，我们对CPR数据准确性的了解与其重要性不相称，需要进一步研究。我们提出了研究准确性的方法指南，以解决当前文献的不足之处。随着CPR数据越来越多地用于研究，研究数据库中用于持续监测和提高准确性的方法应应用于CPR。
