vitjВрач и информационные технологииMedical Doctor and Information Technologies1811-01932413-5208Pirogov National Medical and Surgical Center10.25881/18110193_2024_3_6vitj-58Research ArticleОБЗОРЫREVIEWSОбзор методических подходов к оценке качества ведения электронных медицинских картReview of methodological approaches to assessing the quality of electronic health records managementКафтановА. Н.KaftanovA. N.

к.м.н.

Петрозаводск

PhD,

Petrozavodsk

akaftanov@webiomed.ruАндрейченкоА. Е.AndreychenkoA. E.

к.ф.-м.н.

Петрозаводск

PhD

Petrozavodsk

aandreychenko@webiomed.ruГусевА. В.GusevA. V.

к.т.н.

Москва

PhD

Moscow

agusev@webiomed.aiООО «К-СКАЙ»РоссияK-SkaiRussian FederationФГБУ «Центральный научно-исследовательский институт организации и информатизации здравоохранения» Минздрава РоссииРоссияFederal Research Institute for Health Organization and InformaticsRussian Federation20241410202403619Copyright © Кафтанов А.Н., Андрейченко А.Е., Гусев А.В., 20242024Кафтанов А.Н., Андрейченко А.Е., Гусев А.В.Kaftanov A.N., Andreychenko A.E., Gusev A.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.vit-j.ru/jour/article/view/58

Переход на ведение электронных медицинских карт (ЭМК) является одним из базовых направлений цифровой трансформации здравоохранения. Одной из актуальных современных проблем ведения ЭМК является качество данных, которые накапливаются в современных медицинских информационных системах. Учитывая растущую роль ЭМК в качестве источника информации для систем поддержки принятия врачебных решений, внедрение элементов управления на основе первичных данных, а также развитие исследований в сфере данных реальной клинической практики (RWD), возрастает потребность в надежных и объективных методах оценки качества данных, накапливаемых в ЭМК. В этой связи разработка надежных методов и инструментов оценки качества данных (ОКД) в ЭМК является актуальной научной задачей.

Цель

Цель. Изучить и систематизировать предложенные в научной литературе подходы, методы и критерии ОКД ЭМК.

Материалы и методы

Материалы и методы. Были изучены обзоры и оригинальные работы по тематике ОКД ЭМК. Источники были выявлены в результате систематического поиска в четырех электронных библиографических базах данных: PubMed, Web of Science, Scopus и РИНЦ.

Результаты

Результаты. В работе представлены основные подходы и критерии оценки качества данных ЭМК, проведена гармонизация терминов и определений ОКД, выделены ключевые компоненты, необходимые для внедрения системы ОКД ЭМК.

Заключение

Заключение. Сформулированные в обзоре типовые критерии ОКД ЭМК могут быть использованы для дальнейших исследований и разработок инструментов ОКД, в том числе со стороны разработчиков медицинских информационных систем и организаторов здравоохранения, ответственных за цифровую трансформацию отрасли. Также данная работа поможет устранить путаницу в вопросах управления качеством данных ЭМК и предоставит руководство, необходимое для разработки эффективных программ для проведения ОКД.

Transition to electronic medical records (EMR) is one of the basic directions of digital transformation of healthcare.

One of the urgent modern problems of EMR management is the quality of data that are accumulated in modern medical information systems. Given the growing role of EMRs as a source of information for medical decision support systems, the introduction of management elements based on primary data, and the development of research in the field of real-world clinical practice data (RWD), there is a growing need for reliable and objective methods to assess the quality of data accumulated in EMRs. In this regard, the development of reliable methods and tools for data quality assessment (DQA) in EMR is an urgent scientific task.

Aim

Aim. To study and systematize the approaches, methods and criteria of proposed in the scientific literature.

Materials and Methods

Materials and Methods. Reviews and original articles on the subject of EMRs DQA were studied. Sources were identified by systematic search in four electronic bibliographic databases: PubMed, Web of Science, Scopus and RSCI.

Results

Results. The paper presents the main approaches and criteria for assessing the quality of EMR data, harmonizes the terms and definitions of DQA, and identifies the key components required to implement an EMRs DQA system.

Conclusion

Conclusion. The generic EMRs DQA criteria formulated in the review can be used for further research and development of DQA tools, including by medical information system developers and health care organizers responsible for the digital transformation of the industry. Also, this work will help eliminate confusion about EMR data quality management and provide the guidance needed to develop effective DQA programs.

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The authors declare that there are no conflicts of interest present.