Variation in Laboratory Test Naming Conventions in EHRs Within and Between Hospitals: A Nationwide Longitudinal Study.
Variation in Laboratory Test Naming Conventions in EHRs Within and Between Hospitals: A Nationwide Longitudinal Study.
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DOI：
10.1097/mlr.0000000000000996
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发表时间：
2019-04
期刊：
影响因子：
3
通讯作者：
Iwashyna TJ
中科院分区：
文献类型：
--
作者：
Wiitala WL;Vincent BM;Burns JA;Prescott HC;Waljee AK;Cohen GR;Iwashyna TJ
电子健康记录(EHR)为研究和质量改进工作提供了丰富的临床数据。然而，这些数据往往是非结构化的文本，可能会被不一致地记录并提取到中央数据库中，使其难以用于研究。我们试图量化关键实验室在退伍军人事务部(VA)企业数据仓库(CDW)中跨医院和随时间的记录方式的变化。我们纳入了2005-2015财年通常在入院后24小时内抽取的六个实验室(白蛋白、胆红素、肌酐、血红蛋白、钠、白细胞计数(WBC))。我们评估了退伍军人事务部121个地点5,454,411例急性住院患者的实验室检测捕获情况。标准化实验室命名法(逻辑观察标识符名和代码，LOINC)到CDW检测结果的映射在医院内因实验室检测而异。LOINC和实验室检测名称之间的关系随着时间的推移而改善；到2015财年，109家(95.6%)医院将六个实验室中的90%以上映射到适当的LOINC。附录中提供了用于对测试结果进行分类的所有字段。使用电子病历数据进行研究需要评估数据的一致性和质量。使用实验室测试结果需要使用非结构化文本字段和识别适当的LOINC。在使用来自多个设施的数据时，应按设施仔细检查结果，并随时间推移，以最大限度地捕获数据字段。
Electronic Health Records (EHRs) provide clinically rich data for research and quality improvement work. However, the data is often unstructured text, may be inconsistently recorded and extracted into centralized databases, making them difficult to use for research. We sought to quantify the variation in how key labs are recorded in the Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW) across hospitals and over time. We included six labs commonly drawn within the first 24 hours of hospital admission (albumin, bilirubin, creatinine, hemoglobin, sodium, white blood cell count (WBC)) from fiscal years 2005 – 2015. We assessed laboratory test capture for 5,454,411 acute hospital admissions at 121 sites across the VA. The mapping of standardized laboratory nomenclature (Logical Observation Identifiers Names and Codes, LOINCs) to test results in CDW varied within hospital by laboratory test. The relationship between LOINCs and laboratory test names improved over time; by FY2015, 109 (95.6%) hospitals had more than 90% of the six labs mapped to an appropriate LOINC. All fields used to classify test results are provided in an appendix. The use of EHR data for research requires assessing data consistency and quality. Using laboratory test results requires the use of both unstructured text fields and the identification of appropriate LOINCs. When using data from multiple facilities, the results should be carefully examined by facility and over time to maximize capture of data fields.