Обзор методических подходов к оценке качества ведения электронных медицинских карт

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

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. 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. 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.

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