探索在初级保健环境中最大限度地提高电子医疗记录数据质量和相关效益的实际方法。2014年7月在SAPC举行小组讨论报告

Sheena Dungey, S. Glew, B. Heyes, J. Macleod, A. Rosemary Tate
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引用次数: 3

摘要

电子医疗记录提供了一段时间内患者护理的信息,这不仅提供了通过有效监测和识别护理需求来直接改善患者护理的机会,而且还为临床和服务模式研究提供了一个独特的平台,这对医疗服务的长期发展至关重要。然而,记录数据的质量可能是可变的,并且可能损害数据用于主要目的和次要目的的有效性。为了探索记录高质量初级保健电子记录的挑战和好处以及方法,临床实践研究数据链(CPRD)赞助的研讨会于2014年在学术初级保健学会(SAPC)会议上举行,目的是吸引全科医生和其他数据用户。方法研讨会以结构化讨论的形式举行,由专家小组领导,围绕三个问题进行讨论:(1)临床医生和研究人员的数据质量优先事项是什么?这些优先级是如何不同或重叠的?(2)全科医生在为治疗病人和研究提供高质量的数据方面可能面临哪些挑战?这些目标有冲突吗?(3)哪些工具(如数据度量和可视化或软件组件)可以帮助全科医生提高数据质量和患者管理,这是否可以与研究阶段发生的分析过程相结合?结果:讨论强调了不同用户群体在感知数据质量优先级和挑战方面的重叠和差异。会议商定了五个重点领域,并确定了进一步提高质量的建议。结论良好的高质量电子医疗记录的重要性已经提出,以及需要一个实用的用户考虑和协作的方法来改进它。
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Exploring practical approaches to maximising data quality in electronic healthcare records in the primary care setting and associated benefits. Report of panel-led discussion held at SAPC in July 2014
Background Electronic healthcare records provide information about patient care over time which not only affords the opportunity to improve patient care directly through effective monitoring and identification of care requirements but also offers a unique platform for both clinical and service-model research essential to the longer-term development of the health service. The quality of the recorded data can, however, be variable and can compromise the validity of data use both for primary and secondary purposes. Objectives In order to explore the challenges and benefits of and approaches to recording high quality primary care electronic records, a Clinical Practice Research Datalink (CPRD) sponsored workshop was held at the Society of Academic Primary Care (SAPC) conference in 2014 with the aim of engaging GPs and other data users. Methods The workshop was held as a structured discussion, led by an expert panel and focused around three questions: (1) What are the data quality priorities for clinicians and researchers? How do these priorities differ or overlap? (2) What challenges might GPs face in provision of good data quality both for treating their patients and for research? Do these aims conflict? (3) What tools (such as data metrics and visualisations or software components) could assist the GP in improving data quality and patient management and could this tie in with analytical processes occurring at the research stage? Results The discussion highlighted both overlap and differences in the perceived data quality priorities and challenges for different user groups. Five key areas of focus were agreed upon and recommendations determined for moving forward in improving quality. Conclusions The importance of good high quality electronic healthcare records has been set forth along with the need for a practical user-considered and collaborative approach to its improvement.
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