Assessing the accuracy of administrative data in health information systems

Administrative data play a central role in health care. Inaccuracies in such data are costly to health systems, they obscure health research, and they affect the quality of patient care. We sought to prospectively determine the accuracy of the primary and secondary diagnoses recorded in administrati...

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Veröffentlicht in:	Medical care Jg. 42; H. 11; S. 1066
Hauptverfasser:	Peabody, John W, Luck, Jeff, Jain, Sharad, Bertenthal, Dan, Glassman, Peter
Format:	Journal Article
Sprache:	Englisch
Veröffentlicht:	United States 01.11.2004
Schlagworte:	Cohort Studies Diagnosis Diagnostic Errors - statistics & numerical data Forms and Records Control - standards Hospitals, Private - standards Hospitals, Private - statistics & numerical data Hospitals, Veterans - standards Hospitals, Veterans - statistics & numerical data Humans Internal Medicine - standards Medical Records Systems, Computerized - standards Outpatient Clinics, Hospital - standards Outpatient Clinics, Hospital - statistics & numerical data Patient Simulation Prospective Studies Research Design United States United States Department of Veterans Affairs
ISSN:	0025-7079
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Abstract	Administrative data play a central role in health care. Inaccuracies in such data are costly to health systems, they obscure health research, and they affect the quality of patient care. We sought to prospectively determine the accuracy of the primary and secondary diagnoses recorded in administrative data sets. Between March and July 2002, standardized patients (SPs) completed unannounced visits at 3 sites. We abstracted the 348 medical records from these visits to obtain the written diagnoses made by physicians. We also examined the patient files to identify the diagnoses recorded on the administrative encounter forms and extracted data from the computerized administrative databases. Because the correct diagnosis was defined by the SP visit, we could determine whether the final diagnosis in the administrative data set was correct and, if not, whether it was caused by physician diagnostic error, missing encounter forms, or incorrectly filled out forms. General internal medicine outpatient clinics at 2 Veterans Administration facilities and a large, private medical center participated in this study. A total of 45 trained SPs presented to physicians with 4 common outpatient conditions. The correct primary diagnosis was recorded for 57% of visits. Thirteen percent of errors were caused by physician diagnostic error, 8% to missing encounter forms, and 22% to incorrectly entered data. Findings varied by condition and site but not by level of training. Accuracy of secondary diagnosis data (27%) was even poorer. Although more research is needed to evaluate the cause of inaccuracies and the relative contributions of patient, provider, and system level effects, it appears that significant inaccuracies in administrative data are common. Interventions aimed at correcting these errors appear feasible.
AbstractList	Administrative data play a central role in health care. Inaccuracies in such data are costly to health systems, they obscure health research, and they affect the quality of patient care.BACKGROUNDAdministrative data play a central role in health care. Inaccuracies in such data are costly to health systems, they obscure health research, and they affect the quality of patient care.We sought to prospectively determine the accuracy of the primary and secondary diagnoses recorded in administrative data sets.OBJECTIVESWe sought to prospectively determine the accuracy of the primary and secondary diagnoses recorded in administrative data sets.Between March and July 2002, standardized patients (SPs) completed unannounced visits at 3 sites. We abstracted the 348 medical records from these visits to obtain the written diagnoses made by physicians. We also examined the patient files to identify the diagnoses recorded on the administrative encounter forms and extracted data from the computerized administrative databases. Because the correct diagnosis was defined by the SP visit, we could determine whether the final diagnosis in the administrative data set was correct and, if not, whether it was caused by physician diagnostic error, missing encounter forms, or incorrectly filled out forms.RESEARCH DESIGNBetween March and July 2002, standardized patients (SPs) completed unannounced visits at 3 sites. We abstracted the 348 medical records from these visits to obtain the written diagnoses made by physicians. We also examined the patient files to identify the diagnoses recorded on the administrative encounter forms and extracted data from the computerized administrative databases. Because the correct diagnosis was defined by the SP visit, we could determine whether the final diagnosis in the administrative data set was correct and, if not, whether it was caused by physician diagnostic error, missing encounter forms, or incorrectly filled out forms.General internal medicine outpatient clinics at 2 Veterans Administration facilities and a large, private medical center participated in this study.SUBJECTSGeneral internal medicine outpatient clinics at 2 Veterans Administration facilities and a large, private medical center participated in this study.A total of 45 trained SPs presented to physicians with 4 common outpatient conditions.MEASURESA total of 45 trained SPs presented to physicians with 4 common outpatient conditions.The correct primary diagnosis was recorded for 57% of visits. Thirteen percent of errors were caused by physician diagnostic error, 8% to missing encounter forms, and 22% to incorrectly entered data. Findings varied by condition and site but not by level of training. Accuracy of secondary diagnosis data (27%) was even poorer.RESULTSThe correct primary diagnosis was recorded for 57% of visits. Thirteen percent of errors were caused by physician diagnostic error, 8% to missing encounter forms, and 22% to incorrectly entered data. Findings varied by condition and site but not by level of training. Accuracy of secondary diagnosis data (27%) was even poorer.Although more research is needed to evaluate the cause of inaccuracies and the relative contributions of patient, provider, and system level effects, it appears that significant inaccuracies in administrative data are common. Interventions aimed at correcting these errors appear feasible.CONCLUSIONSAlthough more research is needed to evaluate the cause of inaccuracies and the relative contributions of patient, provider, and system level effects, it appears that significant inaccuracies in administrative data are common. Interventions aimed at correcting these errors appear feasible. Administrative data play a central role in health care. Inaccuracies in such data are costly to health systems, they obscure health research, and they affect the quality of patient care. We sought to prospectively determine the accuracy of the primary and secondary diagnoses recorded in administrative data sets. Between March and July 2002, standardized patients (SPs) completed unannounced visits at 3 sites. We abstracted the 348 medical records from these visits to obtain the written diagnoses made by physicians. We also examined the patient files to identify the diagnoses recorded on the administrative encounter forms and extracted data from the computerized administrative databases. Because the correct diagnosis was defined by the SP visit, we could determine whether the final diagnosis in the administrative data set was correct and, if not, whether it was caused by physician diagnostic error, missing encounter forms, or incorrectly filled out forms. General internal medicine outpatient clinics at 2 Veterans Administration facilities and a large, private medical center participated in this study. A total of 45 trained SPs presented to physicians with 4 common outpatient conditions. The correct primary diagnosis was recorded for 57% of visits. Thirteen percent of errors were caused by physician diagnostic error, 8% to missing encounter forms, and 22% to incorrectly entered data. Findings varied by condition and site but not by level of training. Accuracy of secondary diagnosis data (27%) was even poorer. Although more research is needed to evaluate the cause of inaccuracies and the relative contributions of patient, provider, and system level effects, it appears that significant inaccuracies in administrative data are common. Interventions aimed at correcting these errors appear feasible.
Author	Glassman, Peter Bertenthal, Dan Jain, Sharad Peabody, John W Luck, Jeff
Author_xml	– sequence: 1 givenname: John W surname: Peabody fullname: Peabody, John W email: peabody@psg.ucsf.edu organization: San Francisco Veterans Affairs Medical Center, San Francisco, California, USA. peabody@psg.ucsf.edu – sequence: 2 givenname: Jeff surname: Luck fullname: Luck, Jeff – sequence: 3 givenname: Sharad surname: Jain fullname: Jain, Sharad – sequence: 4 givenname: Dan surname: Bertenthal fullname: Bertenthal, Dan – sequence: 5 givenname: Peter surname: Glassman fullname: Glassman, Peter
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SubjectTerms	Cohort Studies Diagnosis Diagnostic Errors - statistics & numerical data Forms and Records Control - standards Hospitals, Private - standards Hospitals, Private - statistics & numerical data Hospitals, Veterans - standards Hospitals, Veterans - statistics & numerical data Humans Internal Medicine - standards Medical Records Systems, Computerized - standards Outpatient Clinics, Hospital - standards Outpatient Clinics, Hospital - statistics & numerical data Patient Simulation Prospective Studies Research Design United States United States Department of Veterans Affairs
Title	Assessing the accuracy of administrative data in health information systems
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