Initial Steps toward Validating and Measuring the Quality of Computerized Provider Documentation

Concerns exist about the quality of electronic health care documentation. Prior studies have focused on physicians. This investigation studied document quality perceptions of practitioners (including physicians), nurses and administrative staff.

An instrument developed from staff interviews and literature sources was administered to 110 practitioners, nurses and administrative staff. Short, long and original versions of records were rated.

Length transformation did not affect quality ratings. On several scales practitioners rated notes less favorably than administrators or nurses. The original source document was associated with the quality rating, as was tf·idf, a relevance statistic computed from document text. Tf·idf was strongly associated with practitioner quality ratings.

Document quality estimates were not sensitive to modifying redundancy in documents. Some perceptions of quality differ by role. Intrinsic document properties are associated with staff judgments of document quality. For practitioners, the tf·idf statistic was strongly associated with the quality dimensions evaluated.