Michelle Greiver, Jan Barnsley, Babak Aliarzadeh, Paul Krueger, Rahim Moineddin, Debra A Butt, Edita Dolabchian, Liisa Jaakkimainen, Karim Keshavjee, David White, David Kaplan
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引用次数: 28
摘要
背景:众所周知,电子病历(EMR)数据的质量存在问题;需要研究如何改进这些数据。目的:主要目的是探讨使用数据录入员对提高初级保健电子病历数据质量的影响。第二个目的是评估实施这一干预措施的可行性。方法:本初步研究采用前后对照设计。参与者是加拿大多伦多的13名社区家庭医生和4名专职保健专业人员。使用由数据管理员编写的查询,数据文员的任务是重新输入电子病历信息,作为慢性阻塞性肺疾病(COPD)、吸烟、专家指定和跨专业会诊标题的编码或结构化数据。我们在干预前和干预后三到六个月测量数据质量。我们通过测量临床医生的可接受性和职员的工作量来评估可行性。结果:干预后,COPD编码条目增加38% (P = 0.0001, 95% CI 23 ~ 51%);可识别的吸烟类别数据增加了27% (P = 0.0001, 95% CI 26 - 29%);专科转诊增加了20% (P = 0.0001, 95% CI 16 - 22%);可识别的跨专业header增加了10% (P = 0.45, 95 CI -3至23%)。总体而言,该干预措施被评为至少中等有用和中等可用。数据录入员花了127个小时重组11729名患者的数据。结论:使用数据管理器进行查询,使用数据办事员重新输入数据,可以提高EMR数据质量。临床医生认为这种方法是可以接受的。
Using a data entry clerk to improve data quality in primary care electronic medical records: a pilot study.
Background: The quality of electronic medical record (EMR) data is known to be problematic; research on improving these data is needed.
Objective: The primary objective was to explore the impact of using a data entry clerk to improve data quality in primary care EMRs. The secondary objective was to evaluate the feasibility of implementing this intervention.
Methods: We used a before and after design for this pilot study. The participants were 13 community based family physicians and four allied health professionals in Toronto, Canada. Using queries programmed by a data manager, a data clerk was tasked with re-entering EMR information as coded or structured data for chronic obstructive pulmonary disease (COPD), smoking, specialist designations and interprofessional encounter headers. We measured data quality before and three to six months after the intervention. We evaluated feasibility by measuring acceptability to clinicians and workload for the clerk.
Results: After the intervention, coded COPD entries increased by 38% (P = 0.0001, 95% CI 23 to 51%); identifiable data on smoking categories increased by 27% (P = 0.0001, 95% CI 26 to 29%); referrals with specialist designations increased by 20% (P = 0.0001, 95% CI 16 to 22%); and identifiable interprofessional headers increased by 10% (P = 0.45, 95 CI -3 to 23%). Overall, the intervention was rated as being at least moderately useful and moderately usable. The data entry clerk spent 127 hours restructuring data for 11 729 patients.
Conclusions: Utilising a data manager for queries and a data clerk to re-enter data led to improvements in EMR data quality. Clinicians found this approach to be acceptable.