作为日常临床实践的一部分,临床医生报告的常规报告的鲁瑟福分数的有效性
Laura L M van der Heijden1,2, Perla J Marang-van de Mheen2, Louis Thielman1
1Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium.
概括
在电子健康记录中例行收集的鲁瑟福分数显示与医疗记录审查的实质一致,表明它们对二次数据使用的有效性. 这支持可靠的重用结构化临床数据用于各种目的.
科学领域:
- 医疗信息学 医疗信息学
- 血管外科 血管外科
- 验证健康数据验证
背景情况:
- 电子健康记录 (EHR) 的结构化数据经常被用于次要目的.
- 这种例行报告的数据对于重复使用的有效性尚未得到充分证实.
- 评估数据有效性对于可靠的二次数据分析至关重要.
研究的目的:
- 为了评估临床医生报告的鲁瑟福分数的有效性,作为结构化EHR数据准确性的指标.
- 为了确定常规收集的鲁瑟福分数与从详细的医疗记录审查中获得的分数之间的一致性.
主要方法:
- 一项观察性研究比较了临床医生报告的鲁瑟福分数与医疗记录审查分数.
- 2016年4月至2018年12月期间,从血管外科部门收集了数据.
- 用弗莱斯的卡帕统计数据来评估协议,使用自由文本字段进行审查评分.
主要成果:
- 总共有6633次访问被分析.
- 在临床医生和审查分数之间发现了两条腿的实质性一致性 (k=0.62).
- 除了缺少的分数,导致几乎完美的一致 (k=0.84-0.85),需要最小的专家判断.
结论:
- 临床医生报告的鲁瑟福分数表明与医疗记录审查的实质一致.
- 这表明,EHR中常规报告的结构化数据可以用于二次用途.
- 定期收集的拉瑟福乐谱的二次使用是各种应用的可行选择.
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