Ekstrom M K, Orthner H F, Warner H R
Department of Medical Informatics, University of Utah, Salt Lake City, USA.
Proc AMIA Annu Fall Symp. 1997:2-6.
Clinical reports, notes, and other narratives are highly used components in the patient record. Unfortunately, the methods by which these reports are generated are as diverse as the fiscal autonomy of academic clinical departments in a university-based health science center. In this paper, we report on electronically capturing clinical reports, notes, and other text fragments from several hospital sources and many outpatient clinics. The purpose of the capture is to feed the ACIS (Advanced Clinical Information System) central patient data repository that is in use at the University of Utah Health Sciences Center (UUHSC). A survey conducted in early 1994 indicated that about 917,150 reports were generated per year at UUHSC representing about 1.2 million pieces of paper, occupying about 2.3 gigabytes of storage. The most crucial problem encountered in capturing the reports was linking them to the proper patient. Systems that had functioning and well-maintained admit-discharge-transfer (ADT) information performed well, but systems that relied on the human dictator to identify patients, produced patient linkage errors. In our open loop telephone dictation systems this error rate averaged between 6 and 10%. Subsequent to the wide-spread availability of clinical reports on ACIS, this error rate dropped to 3-5%, presumably due to increased demand for on-line availability of this information. From clinical secretaries who use their word processor to create the clinical reports, the linkage error rate was < 1% due to the use of our Advanced Text Upload (ATU) utility. The clinical text component in ACIS contributed significantly to the success of a JCAHO site visit in December 1995.
临床报告、记录及其他叙述性文档是患者病历中大量使用的组成部分。不幸的是，生成这些报告的方法如同大学健康科学中心学术临床科室的财务自主权一样多种多样。在本文中，我们报告了从几家医院来源和众多门诊诊所电子捕获临床报告、记录及其他文本片段的情况。捕获的目的是为犹他大学健康科学中心（UUHSC）正在使用的ACIS（高级临床信息系统）中央患者数据存储库提供数据。1994年初进行的一项调查表明，UUHSC每年生成约917,150份报告，相当于约120万张纸，占用约2.3千兆字节的存储空间。在捕获报告过程中遇到的最关键问题是将它们与正确的患者关联起来。拥有正常运行且维护良好的入院-出院-转院（ADT）信息的系统表现良好，但依赖人工口述者识别患者的系统会产生患者关联错误。在我们的开环电话口述系统中，这个错误率平均在6%到10%之间。在ACIS上广泛提供临床报告之后，这个错误率降至3%-5%，大概是由于对该信息在线可用性的需求增加。对于使用文字处理器创建临床报告的临床秘书来说，由于使用了我们的高级文本上传（ATU）实用程序，关联错误率<1%。ACIS中的临床文本组件对1995年12月JCAHO现场检查的成功起到了重要作用。
