How Accurate and Complete are the Contents of General Practitioners' Electronic Medical Record System? 2000

The background for "How Accurate and Complete are the Contents of General Practitioners' Electronic Medical Record System?, 2000" was the improvement potential the data material in electronic pasient journals (EPJs) had, in addition to research on epidemiology and further societal medicine. It was necessary to know more about the extents of the EPJ data, and how this data material could be compiled with what all involved agents knew about the patient. Therefore the project had several objectives: 1) To evaluate the completeness of the data material in EPJs. Was any data missing? 2) Evaluate the correctness of the data material in EPJs. Was the data correct? 3) Describe variations concerning eight frequent diagnosis, between medical offices. 4) Evaluate the practitioner's satisfaction with our feedback and software.

We could by the use of a program called QTools extract fields from EPJs. To find out how extensive the EPJ was, we counted blank fields. To retrieve information concerning correctness, we used several methods. For example we tied together different EPJ fields, for example diagnosis and medication, to identify each patient with a particular medical condition. Short informal interviews with practitioners and employees gave us more information concerning the data of the practices. The data material in practitioners' EPJs were very extensive, except for some fields (for example smoking, habits and field of work), but to interpret the correctness, a great caution was needed. A large part of the EPJs could be used for quality improvement and research, but one would then have to analyze the data material in close cooperation with the practices.

《2000年「全科医生电子病历系统内容的准确性与完整性如何？」》的研究背景为：除流行病学与社会医学相关研究外，全科医生所使用的电子病历（Electronic Patient Journals, EPJs）所依托的数据素材存在显著优化潜力。彼时亟需更全面地了解电子病历数据的覆盖范围，以及如何将该类数据与所有相关主体掌握的患者信息进行整合。因此本项目设定了四项核心研究目标：1）评估电子病历数据素材的完整性，排查数据缺失情况；2）评估电子病历数据素材的正确性，验证数据准确性；3）描述八类常见诊断在不同医疗机构间的分布差异；4）评估全科医生对研究反馈与配套软件的满意度。

研究团队借助一款名为QTools的程序，从电子病历中提取字段信息。为明确电子病历的数据覆盖广度，团队对空白字段进行了统计。为获取数据正确性相关的验证信息，研究采用了多种方法：例如将不同电子病历字段（如诊断信息与用药记录）进行关联匹配，以识别出患有特定疾病的患者。通过对全科医生与医疗机构工作人员开展简短的非正式访谈，团队进一步获取了与医疗机构数据相关的补充信息。

研究结果显示，全科医生的电子病历数据素材整体覆盖范围较广，但部分字段（如吸烟史、生活习惯与职业领域等）存在缺失。然而在解读数据正确性时，需保持高度审慎。尽管绝大多数电子病历数据可用于医疗质量改进与相关研究，但在此类应用场景中，需与医疗机构紧密协作开展数据分析工作。