Data gaps in electronic health record (EHR) systems: An audit of problem list completeness during the COVID-19 pandemic.
Data gaps in electronic health record (EHR) systems: An audit of problem list completeness during the COVID-19 pandemic.
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DOI：
10.1016/j.ijmedinf.2021.104452
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发表时间：
2021-06
影响因子：
4.9
通讯作者：
Shah, Anoop D.
中科院分区：
文献类型：
--
作者：
Poulos, Jordan;Zhu, Leilei;Shah, Anoop D.
关键词：
评估COVID-19大流行期间医院电子健康记录（EHR）系统中问题列表中诊断记录的完整性。回顾性病历审查与自由文本电子病历的手动审查。在英国COVID-19大流行的第一个高峰期，综合EHR系统（Epic）推出一年后，位于伦敦的主要教学医院信托基金。516名疑似或确诊COVID-19患者。已包含在结构化问题列表中的诊断百分比。在审查之前，这些患者在其EHR问题列表中总共记录了2841项诊断。确定了1722个额外的诊断，将每位患者记录的问题的平均数量从5.51增加到8.84。最初纳入问题列表的诊断的总体百分比为62.3%（2841 / 4563，95%置信区间60.8%，63.7%）。以结构化方式存储在电子健康记录中的诊断和其他临床信息对于支持临床决策、改善患者护理和实现更好的研究非常有用。然而，住院病人的结构化问题清单上的医疗诊断记录是不完整的，几乎40%的重要诊断只在自由文本注释中提到。
To evaluate the completeness of diagnosis recording in problem lists in a hospital electronic health record (EHR) system during the COVID-19 pandemic. Retrospective chart review with manual review of free text electronic case notes. Major teaching hospital trust in London, one year after the launch of a comprehensive EHR system (Epic), during the first peak of the COVID-19 pandemic in the UK. 516 patients with suspected or confirmed COVID-19. Percentage of diagnoses already included in the structured problem list. Prior to review, these patients had a combined total of 2841 diagnoses recorded in their EHR problem lists. 1722 additional diagnoses were identified, increasing the mean number of recorded problems per patient from 5.51 to 8.84. The overall percentage of diagnoses originally included in the problem list was 62.3% (2841 / 4563, 95% confidence interval 60.8%, 63.7%). Diagnoses and other clinical information stored in a structured way in electronic health records is extremely useful for supporting clinical decisions, improving patient care and enabling better research. However, recording of medical diagnoses on the structured problem list for inpatients is incomplete, with almost 40% of important diagnoses mentioned only in the free text notes.
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