A process for obtaining patient clinical information in the ambulatory setting

The Wisconsin Ambulatory Review Project is the most extensive study to date with the goal of describing in detail the nature of care in the ambulatory setting. To assist in the description, a detailed, electronic clinical data base was created from a random sample of nonstandard, often hand-written, ambulatory patient medical records. This paper describes the set of processes that enabled significant clinical data to be collected, organized, and made available to researchers, including the collection of a representative sample of patient medical records, the creation of a detailed clinical vocabulary, the implementation of the vocabulary as a data abstraction tool, the collection and aggregation of distributed electronic data files, and the assessment of the efficiency of the abstraction process. The integration of all of these processes has produced a working system that has successfully been deployed as a pilot study across a seven-state area.