Article

By automating collection of data elements, electronic health records may simplify
the process of measuring the quality of medical care. Using data from a quality
improvement initiative in primary care medical groups, we sought to determine
whether the quality of care for falls and fear of falling in outpatients aged 75
and older could be accurately measured solely from codable (non-free-text) data
in a structured visit note. A traditional medical record review by trained
abstractors served as the criterion standard. Among 215 patient records reviewed,
we found a structured visit note in 54% of charts within 3 mo of the date
patients had been identified as having falls or fear of falling. The reliability
of an algorithm based on codable data was at least good (kappa of at least 0.61)
compared with full medical record review for three care processes recommended for
patients with two falls or one fall with injury in the past year: orthostatic
vital signs, vision test/eye examination, and home safety evaluation. However,
the automated algorithm routinely underestimated quality of care. Performance
standards based on automated measurement of quality of care from electronic
health records need to account for documentation occurring in nonstructured form.

Langue : ANGLAIS