Computerized extraction of information on the quality of diabetes care from free text in electronic patient records of general practitioners.

摘要

OBJECTIVE: This study evaluated a computerized method for extracting numeric clinical measurements related to diabetes care from free text in electronic patient records (EPR) of general practitioners. DESIGN AND MEASUREMENTS: Accuracy of this number-oriented approach was compared to manual chart abstraction. Audits measured performance in clinical practice for two commonly used electronic record systems. RESULTS: Numeric measurements embedded within free text of the EPRs constituted 80% of relevant measurements. For 11 of 13 clinical measurements, the study extraction method was 94%-100% sensitive with a positive predictive value (PPV) of 85%-100%. Post-processing increased sensitivity several points and improved PPV to 100%. Application in clinical practice involved processing times averaging 7.8 minutes per 100 patients to extract all relevant data. CONCLUSION: The study method converted numeric clinical information to structured data with high accuracy, and enabled research and quality of care assessments for practices lacking structured data entry.