Using computerized medical databases to measure and to improve the quality of intensive care
Section snippets
Computerized medical databases
There are 2 general types of computerized databases used to assess the quality of medical care (Table 1). One is the administrative database collected for purposes other than direct delivery of medical care. These databases are usually collected for billing purposes, but some are collected specifically with the intent of assessing quality of care and reporting outcomes. For example, the State Inpatient Databases were developed as part of the Healthcare Cost and Utilization Project (HCUP), a
Domains of quality of care
Donabedian proposed a framework for thinking about the quality of medical care that separates quality into 3 components: structure, process, and outcome.8 An instructive analogy for understanding this framework is to imagine a food critic evaluating the quality of a restaurant. The critic might comment on the decoration and lighting of the restaurant, how close the tables are to each other, the breadth of the wine list and where the chef trained. These are all evaluations of the restaurant
Garbage in = garbage out
This age-old programmers’ dictum applies strongly to computerized electronic medical record data. The sheer volume of data collected automatically by many systems does not guarantee its quality nor does the volume insure that the data are unbiased. Many of the functions designed to enhance usability, for example, functions that allow users to copy data from one day to the next can perpetuate these errors rather than reduce them. Some data elements are particularly difficult to analyze. For
Measuring the structure of intensive care with the computerized medical databases
The electronic medical record is not generally well suited to measuring the structure of medical care because the components of structure: technological availability, task diversity, staffing, and caregiver interaction are not routinely assessed in computerized medical databases.14, 15 Computerized medical databases focus on the care of individual patients while the structure of healthcare delivery is measured at the level of the institution. In studies that relate structure of intensive care
Measuring the process of intensive care with the computerized medical databases
As noted previously, process of care variables have several benefits as markers of quality. There is an extensive body of literature documenting the inappropriate delivery, both under- and over-provision, of medical care. Despite a mature evidence database and even when conservative criteria for case selection are used, a significant proportion of patients do not receive appropriate aspirin, heparin, thrombolytic therapy, or beta antagonists in the setting of acute coronary syndromes.3 Similar
Measuring the outcomes of intensive care with the computerized medical databases
The use of the word “outcome” in research can be confusing.1 It can refer to any variable that is the dependent variable in an analysis. For example, in a clinical trial of recombinant human erythropoietin in the ICU, the outcome variable was use of blood transfusions.25 However, in the context of the Donabedian model of measuring quality and with respect to the field of outcomes research, outcomes refer to a variety of variables that measure factors that are important to patients including:
Limits of using computerized medical databases to measure and improve quality of care
There are several problems with using computerized medical databases to measure and improve quality of care. Perhaps the most important of these is actually defining what one means by quality of care. Initial attempts to measure quality of care using computerized medical databases focused on comparing outcomes, usually mortality, between centers.32 The use of risk adjusted outcome, usually mortality, remains a key component in attempts to define, report, and improve quality of care.33, 34 Risk
Ethics of using data from computerized medical databases
Many uses of computerized medical record data fall under the category of routine clinical care and therefore are not covered by research requirements for institutional review. This might include using the electronic medical record to profile physicians and feedback data regarding antibiotic use; to identify resistance patterns in bacteria in the ICU; or to see whether the purchase of new antibiotic coated catheters had reduced the incidence of catheter related bacteremia. Analysis of the
Conclusions
Perhaps the greatest benefits of computerized medical databases are yet to be realized. As computing power shrinks, standards for wireless computing and data sharing become more robust, and clinical users become accustomed to computer interfaces from early on in their career, the seamless integration of computers into clinical practice will be inevitable. Ample evidence exists that timely computer generated prompts and decision support can influence clinical practice.47, 48, 49 In considering
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The positive financial impact of using an Intensive Care Information System in a tertiary Intensive Care Unit
2013, International Journal of Medical InformaticsCitation Excerpt :This has become increasingly possible because more Intensive Care Units are gradually being equipped with clinical information systems. During the past ten years, several publications have shown that the use of computers has not only improved everyday medical practice (e.g. Computerized Clinical Decision Support [CDSS]), but has also positively influenced the development of different databases [17–21]. For coding processes, Pakhomov et al. developed an automated coding system that can assign codes to clinical diagnoses [22].
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2010, CMAJ. Canadian Medical Association JournalEvaluation of drug management information system to improve quality and users satisfaction: Case study at a primary health center
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