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  • 1
    Electronic Resource
    Electronic Resource
    Data quality in computerized patient records (1994)
    Springer
    Journal of clinical monitoring and computing 11 (1994), S. 233-240 
    Details
    ISSN: 1573-2614
    Keywords: computerized patient record ; computerized medical record ; haematology ; cytology database ; electronic data quality ; free text coding
    Source: Springer Online Journal Archives 1860-2000
    Topics: Computer Science , Medicine
    Notes: Abstract This paper addresses the problem of data quality in electronic patient records using a computerized haematology biopsy report system as an example. Physicians extracted five parameters from a traditional free text cytology report and encoded these parameters thus producing a computer processable report. The parameters were 1) the organ biopsied, 2) quality of specimen, 3) cytological diagnosis including 4) a modifier code for the main diagnosis code (i.e. status post chemotherapy, Y-code) and 5) an additional key describing the degree of remission obtained after chemotherapy of acute leukemias. From the various steps involved in generating the electronic record we selected two critical ones: - encoding of free text terms by physician staff - entering of the coded terms into a computer by lab staff. We analyzed the rates of correct, incorrect and missing codes for each of the five parameters. Our findings indicate that in this model of an electronic patient record 1) there is significant inaccuracy of physicians during the process of encoding the free text report with error rates between 3.2 and 28% and omission rates up to 64%. 2) lab staff entering these coded data into the computer introduce additional errors (0–7.8%) but rarely miss correctly encoded data (0–0.9%). 3) introducing a revised coding system data quality improved significantly (p≤0.001) with a fivefold increase of correct and a 75% reduction of missing codes. 4) the clinical relevance of the diagnoses encoded as perceived by clinicians is a significant factor affecting error and omission rates. 5) a significant source of error is the machine/user interface resulting in incorrect data entry of up to 91.7%. 6) when considering all combined errors and omissions in coding and in entering these codes into a computer only 43% of all electronic reports examined were correct and complete. We conclude that the quality of data in electronic patient records can be quite low. Amongst significant factors contributing to low electronic data quality are the type of user interacting with the system, the kind of function the user performs, relevance of codable terms as perceived by physicians, the kind of coding system used and the quality of the human/machine-interface.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01139875
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  • 2
    Electronic Resource
    Electronic Resource
    Coding medical concepts:A controlled experiment with a computerised coding tool (1995)
    Springer
    Journal of clinical monitoring and computing 12 (1995), S. 141-145 
    Details
    ISSN: 1573-2614
    Keywords: coding medical concepts ; diagnoses ; electronic patient record ; ICD-9 ; quality of documentation
    Source: Springer Online Journal Archives 1860-2000
    Topics: Computer Science , Medicine
    Notes: Abstract In clinical routine there is a growing need to encode medical concepts with available standard coding systems. The coding process can be time consuming and may significantly add to daily paperwork, particularly regarding patients with multiple diagnoses and in busy clinical environments with a high turnover of patients. We have developed a generic computerised encoding tool — the PADS encoder — to ensure rapid, correct and complete coding of diagnoses in daily routine. The tool is integrated into an electronic patient record system (PADS, Patient Archiving & Documentation System) and takes full advantage of the user friendly Macintosh interface. The tool was tested in a controlled experiment by 18 clinicians who encoded a total of 666 medical concepts in each protocol (study protocol vs. control). The following positive findings were significantly associated with the use of the computerised coding tool: - the number of correctly encoded medical concepts was higher (99.55% vs. 86.1%) - coding errors were lower (0% vs. 10.81%) - more modifier codes were encoded correctly (increase by up to 43%) - less coding errors were made (decrease by up to 43%) - the overall rate of correctly encoded and complete main and modifier codes was increased by 31.27% (97.29% vs. 66.02%) - coding time was reduced by 50% This paper presents data to suggest that a computerised coding tool can produce more complete data of higher quality and can save time compared with the traditional approach to encode medical concepts.
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF02332688
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  • 3
    Electronic Resource
    Electronic Resource
    PADS (Patient Archiving and Documentation System): A computerized patient record with educational aspects (1992)
    Springer
    Journal of clinical monitoring and computing 9 (1992), S. 71-84 
    Details
    ISSN: 1573-2614
    Keywords: Computerized Patient Record ; Medical Record ; patient documentation ; Macintosh ; ORACLE ; 4th dimension ; local are network (LAN) ; Intensive Care Unit (ICU) ; graphical user interface (GUI) ; relational database management system (RDBMS) ; personal computer (PC)
    Source: Springer Online Journal Archives 1860-2000
    Topics: Computer Science , Medicine
    Notes: Summary Rapid acquisition and analysis of information in an Intensive Care Unit (ICU) setting is essential, even more so the documentation of the decision making process which has vital consequences for the lifes of ICU patients. We describe an Ethernet based local area network (LAN) with clinical workstations (Macintosh fx, ci). Our Patient Archiving and Documentation System (PADS) represents a computerized patient record presently used in a university hospitals' ICU. Taking full advantage of the Macintosh based graphical user interface (GUI) our system enables nurses and doctors to perform the following tasks: admission, medical history taking, physical examination, generation of problem lists and follow up notes, access to laboratory data and reports, semiautomatic generation of a discharge summary including full word processor capabilities. Furthermore, the system offers rapid, consistent and complete automatic encoding of diagnoses following the International Classification of Disease (ICD; WHO, [1]). For educational purposes the user can also view disease entities or complications related to the diagnoses she/he encoded. The system has links to other educational programs such as cardiac auscultation. A MEDLINE literature search through a CD-ROM based system can be performed without exiting the system; also, CD-ROM based medical textbooks can be accessed as well. Commercially available Macintosh programs can be integrated in the system without exiting the main program thus enabling users to customize their working enviroment. Additional options include automatic background monitoring of users learning behavior, analyses and graphical display of numerous epidemiological and health care related problems. Furthermore, we are in the process of integrating sound and digital video in our system. This system represents one in a line of modular departmental models which will eventually be integrated to form a decentralized Hospital Information System (HIS).
    Type of Medium: Electronic Resource
    URL: http://dx.doi.org/10.1007/BF01142184
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