2011 — Medical Record Data in an Era of Electronic Records

Hogan MM (VA Ann Arbor Healthcare System), Murff HJ (Tennessee Valley HCS), Robinson CH (VA Ann Arbor HCS), Asch SA (VA Greater Los Angeles HCS)

Workshop Objectives:
Health services research has long depended upon medical record information as a data source. VHA’s electronic medical record has led to new opportunities for use of this data for research. The presenters have experience using a variety of medical record review methods. Through workshop activities, participants will consider 1) benefits and limitations of data sources and methods, i.e., automated data, reviewer abstraction, and text searching, 2) techniques for transforming research questions into abstraction tools or text search algorithms, 3) lessons learned from working with human abstractors, and 4) use of text mining for extracting information from narrative records.

Activities:
This presentation will have several activities to demonstrate medical record review methods, primarily focusing on use of abstractors and text searching rather than automated data. Text searching is a relatively new option. Participants will explore the differences in information and interpretation using differing data types. First, participants will examine automated data for conditions or medications on several “patients.” Then they will review selected progress notes and pharmacy records on these same patients. Through this experience participants will compare and contrast what may be learned from differing data sources. This will set the stage for participants’ consideration of when to use abstractors or text searching instead of or in combination with automated data. Then, to illustrate how to use each method, presenters will guide participants in developing specific abstraction questions or text search algorithms to answer a research question. When using abstractors, the need for training, supervision, reliability testing, and quality assurance are well-recognized, but some human resources issues are not. We will share some lessons learned from working with abstractors, who are often temporary, less-involved members of the research team.

Target Audience:
Health services researchers with interest in medical records review as a source of health services research data.

Assumed Audience Familiarity with Topic:
Some familiarity with VA’s health care system, electronic medical record system, and data sources would be helpful, but is not required.