一个临床结果数据档案,用于一个全面的胎儿诊断和治疗中心
Thomas A Reynolds1, Matthew A Goldshore1,2, Sabrina Flohr1
1The Richard D. Wood Jr. Center for Fetal Diagnosis & Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
Fetal diagnosis and therapy
|October 8, 2024
概括
一个新的平台,临床结果数据档案 (CODA),通过合并电子健康记录和手动抽象来改善母胎健康数据的收集,以改善患者护理和研究. 该系统提高了先天性异常和纵向研究的数据准确性.
科学领域:
- 孕产妇和胎儿医学 孕产妇和胎儿医学
- 医疗信息学 医疗信息学
- 临床数据管理 临床数据管理
背景情况:
- 准确的临床结果数据对于母胎患者至关重要,特别是对于长期的神经发育评估.
- 电子健康记录 (EHR) 在数据捕获方面存在挑战,原因是文件不一致,缺乏统一的胎儿数字身份.
- 现有的系统经常产生不完整的数据,阻碍了影响母婴健康结果的因素的分析.
研究的目的:
- 开发和实施一个潜在的数据采集平台,即临床结果数据档案 (CODA).
- 将电子健康记录 (EHR) 数据转化为分析级数据库,用于母胎医学中的多用途.
- 改善先天性异常患者临床表现和护理轨迹的表征.
主要方法:
- 构建了一个统一的平台 (CODA),用于对母婴双进行纵向跟踪.
- 设计了基于专家输入的数据词典和患者,胎儿和怀孕的关系身份的CODA.
- 通过训练有素的团队验证了EHR来源和图表抽象数据,用于2022年7月至2023年7月期间获得的数据.
主要成果:
- 在12种疾病中对7,662名患者验证了5,394,106个数据点.
- 确定2%的数据点不可靠或没有文件,其中91%来自电子健康记录.
- 发现85%的特定条件变量需要手动图表抽象才能完整.
结论:
- CODA成功地将EHR来源和手动抽象的数据合并为纵向母婴双研究.
- 该平台提高了数据质量和完整性,解决了标准EHR数据捕获的局限性.
- 由CODA支持的研究为其他18个研究项目做出了贡献,证明了它的实用性.
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