2026 年第 7 期 第 21 卷

基于电子病历数据的急性心肌梗死住院患者关键循证治疗措施使用率及其准确性验证研究

Study on the utilization rate of key evidence-based treatments and accuracy verification in hospitalized patients with acute myocardial infarction based on electronic medical record data

作者：宋泽利1邓秋菊1刘静1张海波2郝永臣1

英文作者：Song Zeli1 Deng Qiuju1 Liu Jing1 Zhang Haibo2 Hao Yongchen1

单位：1首都医科大学附属北京安贞医院北京市心肺血管疾病研究所临床与流行病研究中心，北京101118；2首都医科大学附属北京安贞医院瓣膜与房颤外科中心，北京101118 宋泽利为首都医科大学临床流行病学与试验学系研究生

英文单位：1Clinical and Epidemiological Research Center Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart Lung and Blood Vessel Diseases Beijing 101118 China; 2Valve and Atrial Fibrillation Surgery Center Beijing Anzhen Hospital Capital Medical University Beijing 101118 China

关键词：急性心肌梗死；电子病历数据；医疗质量评价

英文关键词：Acutemyocardialinfarction;Electronicmedicalrecorddata;Medicalqualityevaluation

• 摘要：

• 目的 基于临床电子病历数据，评价急性心肌梗死(AMI)住院患者关键循证治疗措施使用率，并验证该方法评价结果的准确性。方法 本研究为基于临床常规诊疗数据的横断面研究，纳入北京地区5家医院的900例AMI病例，以人工提取病历数据评价患者诊疗质量为参考标准，对比并验证基于电子病历数据的关键循证治疗措施使用率评价结果的准确性。 结果 入选的5家医院的900例AMI患者基线年龄为(65±14)岁，其中男663例(73.7%)。各医院的AMI医疗质量指标分析显示，电子病历数据与人工病历记录的数据在7项关键指标上呈现一致性，再灌注治疗指标中医院A(均为65.3%)、医院B(84.6%比86.8%，排名均为第1)，且再灌注治疗指标的总体标准化均数差仅为0.06，进一步从效应量角度证实了这种微小差异。表明电子病历数据在记录明确、流程化的诊疗项目时可靠性强。结论 基于电子病历数据评价AMI住院患者关键循证治疗措施使用率，与人工填报数据评价患者的医疗质量相比一致性良好，可以作为信息来源用于评估AMI住院患者的医疗质量。

• Objective To evaluate the utilization rate of key evidence-based treatments in hospitalized patients with acute myocardial infarction (AMI) based on electronic medical record data, and to verify the accuracy of the evaluation results. Methods This cross-sectional study was conducted based on routine clinical diagnosis and treatment data. A total of 900 AMI cases from 5 hospitals in Beijing were enrolled. Taking manually extracted medical record data for evaluating diagnosis and treatment quality as the reference standard, the accuracy of the utilization rate of key evidence-based treatments evaluated by electronic medical record data was compared and verified. Results The baseline age of 900 enrolled AMI patients from 5 hospitals was (65±14) years old, including 663 males (73.7%). Analysis of AMI medical quality indicators in each hospital showed that electronic medical record data were consistent with manually recorded data in seven key indicators. For reperfusion therapy indicators, Hospital A (both 65.3%) and Hospital B (84.6% vs 86.8%, both ranked first) presented consistent results. The overall standardized mean difference of reperfusion therapy indicators was only 0.06, further confirming the tiny difference from the perspective of effect size. It indicated that electronic medical record data have high reliability in recording clearly defined and standardized diagnosis and treatment items. Conclusion The evaluation of the utilization rate of key evidence-based treatments in hospitalized AMI patients based on electronic medical record data has good consistency with medical quality evaluation based on manual data entry, which can be used as an information source to assess the medical quality of hospitalized AMI patients.