Assessing the Quality of Structured Data Entry for the Secondary Use of Electronic Medical Records

InSook Cho

doi:10.4258/jksmi.2009.15.4.423

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Cho: Assessing the Quality of Structured Data Entry for the Secondary Use of Electronic Medical Records

Original Article

Journal of Korean Society of Medical Informatics

Journal of Korean Society of Medical Informatics 2009; 15(4): 423-431.

Published online: 31 December 2009

DOI: https://doi.org/10.4258/jksmi.2009.15.4.423

Assessing the Quality of Structured Data Entry for the Secondary Use of Electronic Medical Records

InSook Cho

Department of Nursing, School of Medicine, Inha University, Korea.

Corresponding Author: InSook Cho, Department of Nursing, School of Medicine, Inha University, 253, Yonghyeon-dong, Nam-gu, Incheon 402-751, Korea. Tel: +82-32-860-8201, Fax: +82-32-874-5880, insook.cho@inha.ac.kr

Received 10 May 2009 Accepted 21 December 2009

Abstract

Objective

The raw material of quality improvement is information, whose building block is data. Data in an electronic medical record system have many secondary uses beyond their primary role in patient care, including research and organizational management. This study investigates the data quality of clinical observations recorded using a structured data entry format and assesses the impact of erroneous data.

Methods

A total of 4,580,846 input events from 3,348 inpatients, gathered over a three year period in a teaching hospital, were analyzed by using a 2-by-2 conceptual matrix framework for the appropriateness of data types and semantics. The data were classified into three categories: fully usable, partially usable, and not usable.

Results

The fully usable data constituted 88.6% of the correctly entered data the remaining 11.4% were erroneous. Among the erroneous data, 0.8% were partially usable (n=3,929), and the remaining 99.2% (n= 510,437) were identified as needing further assessment to improve their quality.

Conclusion

Clinical information systems have increasingly used structured data entry or record templates, but the low quality of collected data has severely limited their secondary use potential.

Keywords: Computerized Medical Records, Data Quality, Structured Data Entry, Secondary Use of Data

Figures and Tables

Figure 1

Judgment and classification process of data adequacy

Table 1

Target data items collected from electronic nursing records in the surgical intensive care unit

^*Indicates the data item that is excluded in the final analysis due to the exclusion criteria. GCS: glosgow coma scale, S.M.C: sensory, motor, circulation

Table 2

Conceptual framework for evaluation of quality of nursing data

Table 3

Data quality analysis based on data types and semantics

Table 4

Distribution of erroneous data entry by data group in the partially usable category

Table 5

Distribution of erroneous data entry by data group in the not usable category

Notes

This work was supported by the Korea Science and Engineering Foundation (KOSEF) grant funded by the Korea government (MOST) (No. 2008-0053032)

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