Improving the quality of EHR recording in primary care: a data quality feedback tool
Improving the quality of EHR recording in primary care: a data quality feedback tool
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DOI：
10.1093/jamia/ocw054
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发表时间：
2017-01-01
影响因子：
6.4
通讯作者：
Verheij, Robert A.
中科院分区：
文献类型：
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作者：
van der Bij, Sjoukje;Khan, Nasra;Verheij, Robert A.
目的：电子健康记录（EHR）数据用于卫生保健提供者之间的信息交换。为此目的，数据的质量至关重要。我们开发了一种数据质量反馈工具，用于评估实践和软件包之间EHR数据质量的差异，作为更大干预的一部分。方法：使用不同的软件包在荷兰的92个实践中应用该工具。实践在2010年和2012年收到了数据质量反馈。结果：我们观察到记录质量有很大差异。例如，具有有意义的诊断代码的护理事件的百分比从30%到100%不等。差异与软件包高度相关。在第一次测量一年后，记录的质量有了明显的提高，差异减小，67%的医生表示他们根据第一次测量的结果积极改变了记录的习惯。大约80%的人发现反馈有助于找出录音问题。其中一个软件供应商根据反馈对功能进行了更改。结论：我们的EHR数据质量反馈工具能够突出实践和软件包之间的差异。因此，它也刺激了改进。由于记录的大量可变性与软件包有关，我们的研究加强了通过标准化EHR软件包的功能可以大大提高数据质量的证据。
Objective: Electronic health record (EHR) data are used to exchange information among health care providers. For this purpose, the quality of the data is essential. We developed a data quality feedback tool that evaluates differences in EHR data quality among practices and software packages as part of a larger intervention.Methods: The tool was applied in 92 practices in the Netherlands using different software packages. Practices received data quality feedback in 2010 and 2012.Results: We observed large differences in the quality of recording. For example, the percentage of episodes of care that had a meaningful diagnostic code ranged from 30% to 100%. Differences were highly related to the software package. A year after the first measurement, the quality of recording had improved significantly and differences decreased, with 67% of the physicians indicating that they had actively changed their recording habits based on the results of the first measurement. About 80% found the feedback helpful in pinpointing recording problems. One of the software vendors made changes in functionality as a result of the feedback.Conclusions: Our EHR data quality feedback tool is capable of highlighting differences among practices and software packages. As such, it also stimulates improvements. As substantial variability in recording is related to the software package, our study strengthens the evidence that data quality can be improved substantially by standardizing the functionalities of EHR software packages.