Abstract
Background/Aims Project teams often require itemized patient information for their research and often engage a medical record technician to help them understand the details of a patient’s utilization. The authors suggest that project teams can either supplant or augment their abstracting efforts by using this person-level VDW (Virtual Data Warehouse) patient medical record report. This report is an inexpensive, quick, and well-organized method to produce a patient medical record using VDW data. Another important benefit of this report is that it also has additional information (such as claims) not readily found in the electronic medical record.
Methods Users of the VDW patient medical record report have access to a wide array of content: diagnosis; DRG and procedure codes and descriptions; outpatient dispenses described by generic name; lab test results; BMI; weight; height; blood pressure; provider department; inpatient admitting source; and discharge status. Users can also opt to include cancer site from the VDW tumor registry. More variables can be added over time. This report includes all encounter types (e.g., inpatient, outpatient, emergency, long-term care, telephone, e-mail) found in the VDW files. In addition, the header includes gender and birth/death year, and users specify a time period. Each data value adds an additional line. It is designed for local review as the report contains PHI.
Results This report is easy to create. Because the layout follows chronological order, the reviewer can quickly understand the patient’s utilization over a specified time period. Analysts, investigators, and providers have used this report. Programmer analysts use this information to guide their coding. Providers and investigators like it because they can quickly review patient utilization. We also often give this report to abstractors as a supplement to the traditional electronic medical record. Caveats: The report only contains information from the VDW, so it is only as complete as a site’s VDW files. The electronic medical record contains much information that is not in the VDW patient medical record report.
Conclusions The VDW patient medical record report is an efficient way for research teams to view and understand patient-level utilization found in the VDW.
