手动抽象与电子健康记录数据用于改善外科手术质量
James L Galloway1, Vivi W Chen2, Jennifer Kramer3
1Veterans Affairs Quality Scholars Program, Atlanta VA Health Care System, Decatur, Georgia; Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
The Journal of surgical research
|January 10, 2026
概括
使用电子健康记录 (EHR) 为退伍军人事务外科质量改进计划 (VASQIP) 自动化数据收集显示了大多数变量的高准确性. 这种自动化可以通过节省资源和提高数据及时性来增强外科质量改进 (QI) 计划.
科学领域:
- 医疗信息学 医疗信息学
- 改善外科手术的质量
- 在医疗保健中的数据科学.
背景情况:
- 手动数据抽象是手术质量改进 (QI) 计划的基准.
- 自动化数据收集可以通过减少资源需求,显著地使QI计划受益.
- 退伍军人事务外科质量改善计划 (VASQIP) 依赖于手动抽象.
研究的目的:
- 与手动抽象的VASQIP变量相比,评估电子健康记录 (EHR) 衍生变量的准确性和一致性.
- 为了确定自动化数据收集对VASQIP的可行性.
- 评估EHR数据在提高手术QI方面的潜力.
主要方法:
- 一个全国性的,横截面分析比较EHR衍生的VASQIP变量与手动抽象的VASQIP变量相关 (2016-2020年).
- 使用科恩的卡帕,灵敏度,特异性和预测值来衡量协议.
- 定义强有力的协议是kappa ≥80%.
主要成果:
- 在113家医院评估了533,164例病例.
- 对于种族和种族的高度一致 (kappa中位数为98.1%).
- 术前风险因素 (中位数为28.6%) 和术后并发症 (中位数为15.1%) 的变量协议.
- 对手术前实验室 (中位数91.9%) 和手术内因素 (中位数93.9%) 的强烈同意.
结论:
- 在许多VASQIP变量的数据收集自动化方面,EHR衍生的相关值显示出高准确性,不包括手术后并发症.
- 自动化可以减少手动数据抽象资源.
- 通过使用EHR数据,可以提高外科QI程序的及时性和稳定性.
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