Medical Record Review Conduction Model for Improving Interrater Reliability of Abstracting Medical-Related Information

Engel, Lisa; Henderson, C.A.; Fergenbaum, Jennifer; Colantonio, Angela

doi:10.1177/0163278709338561

Cited by 29 publications

(24 citation statements)

References 29 publications

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“…4,16 Various sources of bias may affect the initial chart data, including the communication of ailments to a medical professional, followed by the entry of that information into a medical record. The quality of data is therefore infl uenced by whether the required information is available in a form that may be abstracted 4 and is accurate.…”

Section: Discussionmentioning

confidence: 99%

“…In response to a lack of guidance in the literature, Engel et al 16 developed the Medical Record Review (MRR) Conduction Model, which describes and frames the process of chart abstraction. According to this model, data quality is affected by individual entities, including the investigator, abstraction manual, abstractor, data source, abstraction tool, and data quality analysis, in a cyclical process.…”

Section: Discussionmentioning

confidence: 99%

“…ine the reliability of the data critically 15,16 or justify the frequency and timing of reliability checks.…”

Section: In T Er R At Er R El Ia Bil I T Y In Data Col L Ec T Ionmentioning

confidence: 99%

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Methods to Achieve High Interrater Reliability in Data Collection From Primary Care Medical Records

Liddy¹,

Wiens²,

Hogg³

2011

The Annals of Family Medicine

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PURPOSEWe assessed interrater reliability (IRR) of chart abstractors within a randomized trial of cardiovascular care in primary care. We report our fi ndings, and outline issues and provide recommendations related to determining sample size, frequency of verifi cation, and minimum thresholds for 2 measures of IRR: the κ statistic and percent agreement. METHODSWe designed a data quality monitoring procedure having 4 parts: use of standardized protocols and forms, extensive training, continuous monitoring of IRR, and a quality improvement feedback mechanism. Four abstractors checked a 5% sample of charts at 3 time points for a predefi ned set of indicators of the quality of care. We set our quality threshold for IRR at a κ of 0.75, a percent agreement of 95%, or both.RESULTS Abstractors reabstracted a sample of charts in 16 of 27 primary care practices, checking a total of 132 charts with 38 indicators per chart. The overall κ across all items was 0.91 (95% confi dence interval, 0.90-0.92) and the overall percent agreement was 94.3%, signifying excellent agreement between abstractors. We gave feedback to the abstractors to highlight items that had a κ of less than 0.70 or a percent agreement less than 95%. No practice had to have its charts abstracted again because of poor quality.CONCLUSIONS A 5% sampling of charts for quality control using IRR analysis yielded κ and agreement levels that met or exceeded our quality thresholds. Using 3 time points during the chart audit phase allows for early quality control as well as ongoing quality monitoring. Our results can be used as a guide and benchmark for other medical chart review studies in primary care.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Methods to Achieve High Interrater Reliability in Data Collection From Primary Care Medical Records

Liddy¹,

Wiens²,

Hogg³

2011

The Annals of Family Medicine

View full text Add to dashboard Cite

show abstract

“…Importantly, authors have noted a lack of published well-established approaches to retrospective chart review, which leaves the validity and reliability of the method in question [6,7,11]. To understand how validity and reliability affect retrospective chart reviews, it is first important to explain and define each.…”

Section: Retrospective Chart Reviewmentioning

confidence: 99%

“…Using the retrospective chart review method allows researchers to examine, record and understand past clinical events documented in persons' medical charts [4,5]. However, despite retrospective chart review's touted feasibility, issues with the reliability and validity of this data collection method have been identified, due to both the limitations of the chart itself and the guidance in using this method provided in the literature [4,6,7]. It is important to examine the reliability and validity of retrospective chart review used in palliative care research, as the findings of such studies employing this method may ultimately shape how end-of-life care is provided in LTC homes.…”

Section: Introductionmentioning

confidence: 99%