Int J Med Inform - Coded entry versus free-text and alert overrides: what you get depends on how you ask.

Tópicos

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Resumo

RPOSE: A key trade-off in computerized clinical documentation exists between collecting coded data versus free-text. Coded data are more readily computer-readable and easier to reuse in different contexts. However, clinical information often exceeds the scope of commonly available terminologies, and coding may be resisted by providers. Alert override reasons are one domain for which agreed-upon terminologies are rarely used. Few data are available on how the collection of information affects the responses of providers.METHODS: We took advantage of a natural experiment and compared coded and uncoded reasons for drug-drug interaction (DDI) alert overrides entered in two inpatient prescribing systems with an identical DDI database but with one system offering coded reasons and the other free-text entry. We only included alerts which were issued in both sites and which physicians had to acknowledge.RESULTS: Over a one-year study period, 15,636 alerts were issued. The reasons for override entered in the coded approach matched the free-text site in only 46%. When using free-text, physicians provided many reasons not among the coded options, and often reported that they considered the alert inappropriate, including their rationale regarding this. However, the information entered as free-text included many typing and spelling errors, and the same concept was often represented in different ways, e.g. 209 different ways in which "will monitor as recommended" was noted.CONCLUSIONS: The reasons for alert override vary substantially according to the data entry type, which implies that data entry choice may lead to substantial distortion of the underlying data.

Resumo Limpo

rpose key tradeoff computer clinic document exist collect code data versus freetext code data readili computerread easier reus differ context howev clinic inform often exceed scope common avail terminolog code may resist provid alert overrid reason one domain agreedupon terminolog rare use data avail collect inform affect respons providersmethod took advantag natur experi compar code uncod reason drugdrug interact ddi alert overrid enter two inpati prescrib system ident ddi databas one system offer code reason freetext entri includ alert issu site physician acknowledgeresult oneyear studi period alert issu reason overrid enter code approach match freetext site use freetext physician provid mani reason among code option often report consid alert inappropri includ rational regard howev inform enter freetext includ mani type spell error concept often repres differ way eg differ way will monitor recommend notedconclus reason alert overrid vari substanti accord data entri type impli data entri choic may lead substanti distort under data

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