Literature DB >> 22577483

Assessing Electronic Note Quality Using the Physician Documentation Quality Instrument (PDQI-9).

Peter D Stetson1, Suzanne Bakken, Jesse O Wrenn, Eugenia L Siegler.   

Abstract

OBJECTIVE: To refine the Physician Documentation Quality Instrument (PDQI) and test the validity and reliability of the 9-item version (PDQI-9).
METHODS: Three sets each of admission notes, progress notes and discharge summaries were evaluated by two groups of physicians using the PDQI-9 and an overall general assessment: one gold standard group consisting of program or assistant program directors (n=7), and the other of attending physicians or chief residents (n=24). The main measures were criterion-related validity (correlation coefficients between Total PDQI-9 scores and 1-item General Impression scores for each note), discriminant validity (comparison of PDQI-9 scores on notes rated as best and worst using 1-item General Impression score), internal consistency reliability (Cronbach's alpha), and inter-rater reliability (intraclass correlation coefficient (ICC)).
RESULTS: The results were criterion-related validity (r = -.678 to .856), discriminant validity (best versus worst note, t = 9.3, p = .003), internal consistency reliability (Cronbach's alphas = .87-.94), and inter-rater reliability (ICC = .83, CI = .72-.91).
CONCLUSION: The results support the criterion-related and discriminant validity, internal consistency reliability, and inter-rater reliability of the PDQI-9 for rating the quality of electronic physician notes. Tools for assessing note redundancy are required to complement use of PDQI-9. Trials of the PDQI-9 at other institutions, of different size, using different EHRs, and incorporating additional physician specialties and notes of other healthcare providers are needed to confirm its generalizability.

Entities:  

Year:  2012        PMID: 22577483      PMCID: PMC3347480          DOI: 10.4338/aci-2011-11-ra-0070

Source DB:  PubMed          Journal:  Appl Clin Inform        ISSN: 1869-0327            Impact factor:   2.342


  34 in total

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Authors:  Fergus V Coakley; Stefan B Heinze; Clair L Shadbolt; Lawrence H Schwartz; Michelle S Ginsberg; Robert A Lefkowitz; Susan Hilton; Kevin Conlon; Steven Leibel; Alan Tumbull; David M Panicek
Journal:  Acad Radiol       Date:  2003-03       Impact factor: 3.173

2.  The future of health information technology in the patient-centered medical home.

Authors:  David W Bates; Asaf Bitton
Journal:  Health Aff (Millwood)       Date:  2010-04       Impact factor: 6.301

3.  Auditing copy and paste.

Authors:  Reed Gelzer; Terri Hall; Elizabeth Liette; Mary G Reeves; Jennifer Sundby; Anne Tegen; Diana Warner; Lou Ann Wiedemann; Kelly McCormick
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4.  Clinical information technologies and inpatient outcomes: a multiple hospital study.

Authors:  Ruben Amarasingham; Laura Plantinga; Marie Diener-West; Darrell J Gaskin; Neil R Powe
Journal:  Arch Intern Med       Date:  2009-01-26

5.  Quantifying clinical narrative redundancy in an electronic health record.

Authors:  Jesse O Wrenn; Daniel M Stein; Suzanne Bakken; Peter D Stetson
Journal:  J Am Med Inform Assoc       Date:  2010 Jan-Feb       Impact factor: 4.497

6.  The physical attractiveness of electronic physician notes.

Authors:  Thomas H Payne; Rupa Patel; Sally Beahan; Jacquie Zehner
Journal:  AMIA Annu Symp Proc       Date:  2010-11-13

Review 7.  Accuracy of data in computer-based patient records.

Authors:  W R Hogan; M M Wagner
Journal:  J Am Med Inform Assoc       Date:  1997 Sep-Oct       Impact factor: 4.497

8.  The problem oriented record as a basic tool in medical education, patient care and clinical research.

Authors:  L L Weed
Journal:  Ann Clin Res       Date:  1971-06

9.  Problems with medical records.

Authors:  H M Tufo; J J Speidel
Journal:  Med Care       Date:  1971 Nov-Dec       Impact factor: 2.983

10.  Direct text entry in electronic progress notes. An evaluation of input errors.

Authors:  C R Weir; J F Hurdle; M A Felgar; J M Hoffman; B Roth; J R Nebeker
Journal:  Methods Inf Med       Date:  2003       Impact factor: 2.176

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  36 in total

1.  Association of Medical Directors of Information Systems consensus on inpatient electronic health record documentation.

Authors:  J Shoolin; L Ozeran; C Hamann; W Bria
Journal:  Appl Clin Inform       Date:  2013-06-26       Impact factor: 2.342

2.  What do physicians read (and ignore) in electronic progress notes?

Authors:  P J Brown; J L Marquard; B Amster; M Romoser; J Friderici; S Goff; D Fisher
Journal:  Appl Clin Inform       Date:  2014-04-23       Impact factor: 2.342

3.  A comparative observational study of inpatient clinical note-entry and reading/retrieval styles adopted by physicians.

Authors:  Rubina F Rizvi; Kathleen A Harder; Gretchen M Hultman; Terrence J Adam; Michael Kim; Serguei V S Pakhomov; Genevieve B Melton
Journal:  Int J Med Inform       Date:  2016-03-02       Impact factor: 4.046

4.  Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review.

Authors:  Natalie Wiebe; Lucia Otero Varela; Daniel J Niven; Paul E Ronksley; Nicolas Iragorri; Hude Quan
Journal:  J Am Med Inform Assoc       Date:  2019-11-01       Impact factor: 4.497

5.  What are they trying to do?: An analysis of Action Identities in using electronic documentation in an EHR.

Authors:  Charlene R Weir; Catherine Staes; Stacey Slager; Teresa Taft; Valiammai Chidambaram; Heidi Kramer; Bruce E Bray; Seneca Perri Moore
Journal:  AMIA Annu Symp Proc       Date:  2018-04-16

6.  Asynchronous Speech Recognition Affects Physician Editing of Notes.

Authors:  Kevin J Lybarger; Mari Ostendorf; Eve Riskin; Thomas H Payne; Andrew A White; Meliha Yetisgen
Journal:  Appl Clin Inform       Date:  2018-10-17       Impact factor: 2.342

7.  Relationship between documentation method and quality of chronic disease visit notes.

Authors:  P M Neri; L A Volk; S Samaha; S E Pollard; D H Williams; J M Fiskio; E Burdick; S T Edwards; H Ramelson; G D Schiff; D W Bates
Journal:  Appl Clin Inform       Date:  2014-05-14       Impact factor: 2.342

8.  The Use of Evidence-Based, Problem-Oriented Templates as a Clinical Decision Support in an Inpatient Electronic Health Record System.

Authors:  Raj Mehta; Nila S Radhakrishnan; Carrie D Warring; Ankur Jain; Jorge Fuentes; Angela Dolganiuc; Laura S Lourdes; John Busigin; Robert R Leverence
Journal:  Appl Clin Inform       Date:  2016-08-17       Impact factor: 2.342

9.  Duly noted: Lessons from a two-site intervention to assess and improve the quality of clinical documentation in the electronic health record.

Authors:  Laura Fanucchi; Donglin Yan; Rosemarie L Conigliaro
Journal:  Appl Clin Inform       Date:  2016-07-06       Impact factor: 2.342

10.  Improving Continuity of Care via the Discharge Summary.

Authors:  Farrant H Sakaguchi; Leslie A Lenert
Journal:  AMIA Annu Symp Proc       Date:  2015-11-05
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