THE ALABAMA COLLABORATION FOR CARDIOVASCULAR EQUALITY PROJECT- ADAPTING AN ELECTRONIC MEDICAL RECORD ABSTRACTION TOOL FOR USE IN AN URBAN COMMUNITY HOSPITAL SETTING
Author(s)
Maribel Salas, MD, DSc, Assistant Professor1, Sandral Hullett, MD, MPH, CEO2, Jeroan Allison, MD, MS, Associate Professor1, Sakeena Ahmed, MPH, Project Coordinator2, Marc Sussman, MS, Administrator21University of Alabama at Birmingham, Birmingham, AL, USA; 2 Cooper Green Hospital, Birmingham, AL, USA
OBJECTIVES: Many quality improvement research projects rely on abstraction of medical record data. Therefore, the objective of this study was to create and adapt an electronic medical record abstraction tool to collect data of hypertensive patients from a Community Hospital. METHODS: A team of three physicians' experts in clinical research and two researchers identified the domains of interest for the project. They listed the main items by domain. The electronic medical record abstraction tool was created and then, multiple tests were carried out to cross-check domains/items with information already recorded in five medical charts. Three abstractors were trained and a data dictionary for abbreviations was created. To validate the tool, 16 medical records of patients were reviewed independently by 2 medical abstractors who did not have a clinical background. The data abstracted were analyzed for inter-rater reliability. Face to face validity was assessed by a group of three physicians to improve the tool, data abstraction, and to document the proficiency of the abstractors to assure data quality. RESULTS: Forty one medical records have been reviewed using the tool. The average interrater reliability rate was 92%. Average age of abstractors was 23 years and 2 of them had college degree. Most of the information requested by the abstraction tool was recorded on medical charts. CONCLUSIONS: Standardized protocols to review and create tools for reviewing medical charts should be implemented. Efforts should be done to adapt those tools to specific research settings when completing abstractions.
Conference/Value in Health Info
2006-05, ISPOR 2006, Philadelphia, PA
Value in Health, Vol. 9, No.3 (May/June 2006)
Code
PCV46
Topic
Methodological & Statistical Research
Topic Subcategory
Modeling and simulation
Disease
Cardiovascular Disorders