Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance
Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance
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DOI：
10.1016/j.ijmedinf.2008.05.005
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发表时间：
2010-05-01
影响因子：
4.9
通讯作者：
Sarne, David
中科院分区：
文献类型：
--
作者：
Galanter, William L.;Hier, Daniel B.;Sarne, David
目的：问题单是电子病历（EMR）的一个关键要素。问题列表可能对患者的安全和护理质量有很大的贡献。医生对问题列表的记录通常低于预期。方法是需要提高准确性和完整性的问题list.Design：一个自动化的临床决策支持（CDS）的干预设计利用市售的电子病历与计算机化的医嘱输入（CPOE）和CDS。该系统基于住院药物CPOE期间发出的警报，提示临床医生将诊断添加到问题列表中。每个警报进行了研究，为期2个月的implementation.Measurements：措施包括警报的有效性，警报产量，和准确性的问题列表additions.Results：在450张病床的教学医院，在所有2个月的研究期间触发警报的药物订单的数量是1011。对于所有警报，有效警报的可能性（在具有预定义诊断之一的患者中发生的警报）为96 +/-1%。警报发生率（定义为警报导致将问题添加到问题列表时发生）为76 +/-2%。结论：CDS问题列表机制整合到药品订单处理过程中，促进了EMR问题列表的相对准确添加。(C)2008爱思唯尔爱尔兰有限公司保留所有权利。
Objective: The problem list is a key and required element of the electronic medical record (EMR). Problem lists may contribute substantially to patient safety and quality of care. Physician documentation of the problem list is often lower than desired. Methods are needed to improve accuracy and completeness of the problem list.Design: An automated clinical decision support (CDS) intervention was designed utilizing a commercially available EMR with computerized physician order entry (CPOE) and CDS. The system was based on alerts delivered during inpatient medication CPOE that prompted clinicians to add a diagnosis to the problem list. Each alert was studied for a 2-month period after implementation.Measurements: Measures included alert validity, alert yield, and accuracy of problem list additions.Results: At a 450 bed teaching hospital, the number of medication orders which triggered alerts during all 2-month study periods was 1011. For all the alerts, the likelihood of a valid alert (an alert that occurred in patients with one of the predefined diagnoses) was 96 +/- 1%. The alert yield, defined as occuring when an alert led to addition of a problem to the problem list, was 76 +/- 2%. Accurate problem list additions, defined as additions of problems when the problem was determined to be present by expert review, was 95 +/- 1%.Conclusion: The CDS problem list mechanism was integrated into the process of medication order placement and promoted relatively accurate addition of problems to the EMR problem list. (C) 2008 Elsevier Ireland Ltd. All rights reserved.