Medical Imaging Data Reconciliation, Part 2: Clinical Order Entry and Imaging Report Data Reconciliation

作者：Reiner Bruce I^*

来源：Journal of the American College of Radiology, 2011, 8(10): 720-724.

DOI：10.1016/j.jacr.2011.05.004

• Data mining
• physician order entry
• radiology reporting

Data reconciliation in medical imaging is designed to ensure the accuracy and integrity of data across multiple steps in the imaging cycle, ultimately leading to improved continuity of patient care. An integral component of this data reconciliation is tied to the steps of clinical order entry and radiology report creation. The clinical data presented at order entry by the referring clinician influence a number of important imaging decisions, including examination selection, protocol design, image acquisition and processing, and interpretation of the imaging data set. The subsequent data derived from the radiology report have a profound impact on diagnosis, treatment, and overall clinical management. As a result, the reconciliation of clinical order entry and radiology report data affect health care delivery and in many respects are dependent on each other for optimal outcomes. The creation of a standardized reconciliation database that proactively records, tracks, analyzes, and provides feedback to radiologists and clinicians offers the potential to improve the quality and efficiency of patient care, while providing objective accountability measures for individual and institutional health care providers.

• 出版日期2011-10