Missing clinical information during primary care visits
Missing clinical information during primary care visits
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DOI：
10.1001/jama.293.5.565
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发表时间：
2005-02-02
影响因子：
120.7
通讯作者：
Pace, WD
中科院分区：
文献类型：
--
作者：
Smith, PC;Araya-Guerra, R;Pace, WD
背景 初级保健的协调功能是信息密集型的，可能会因临床信息缺失而受到阻碍。然而，初级保健机构中尚未明确调查缺失的临床信息。 目的 描述初级保健临床医生关于缺失临床信息的报告。 设计、设置和参与者 在科罗拉多州流动实践和合作伙伴网络 (SNOCAP) 内的 32 个初级保健诊所进行横断面调查，SNOCAP 是一个基于实践的研究网络联盟，参与改善患者安全医疗错误报告研究的应用策略。 2003 年 5 月至 12 月期间，对 253 名临床医生的 1614 次患者就诊进行了调查。对于 1 个半天的就诊期间的每次就诊，每位临床医生都完成了一份有关患者和就诊特征的调查问卷，并说明是否遗漏了重要的临床信息。还记录了临床医生特征。 主要结果测量 报告缺失临床信息的频率、类型和推测位置；感知到的不利影响、护理延误和额外服务的可能性；以及寻找缺失信息所花费的时间。进行多变量分析以评估缺失信息与患者、就诊或临床医生特征的关系，并调整潜在的混杂因素和聚类影响。结果 临床医生在就诊中报告缺失临床信息的比例为 13.6%；缺失信息包括实验室结果（占所有就诊的 6.1%）、信件/附注（5.4%）、放射学结果（3.8%）、病史和体检（3.7%）以及药物（3.2%）。据报告，缺失的临床信息经常位于其临床系统之外，但位于美国境内 (52.3%)，至少在一定程度上可能对患者产生不利影响 (44%)，并可能导致护理或额外服务的延迟 (59.5%)。据报道，花费了大量时间未能成功搜索缺失的临床信息（5-10 分钟，25.6%；>10 分钟，10.4%）。调整后，当患者是新移民（比值比 [OR]，1.78；95% 置信区间 [CI]，1.06-2.99）、新患者（OR，2.39；95% CI，1.70-3.35）或有多种医疗问题（1 个问题：OR，1.09；95% Cl，1.70-3.35）时，报告缺失的临床信息更有可能发生。 0.69-1.73；2-5 个问题：OR，1、87；95% Cl，1.21-2.89；>5 个问题：OR，2.78；95% Cl，1.61-4.80）。在农村实践中（OR，0.52；95% Cl，0.29-0.92）以及个别临床医生报告拥有完整的电子记录（OR，0.40；95% Cl，0.17-0.94），临床信息缺失的可能性较小。 结论 初级保健临床医生报告说，临床信息缺失是常见的、多方面的，可能会消耗时间和其他资源，并可能对患者产生不利影响。需要对缺失信息进行更多研究，重点是验证临床医生的看法并对其原因和后遗症进行前瞻性研究。
Context The coordinating function of primary care is information-intensive and may be impeded by missing clinical information. However, missing clinical in formation has not been explicitly investigated in the primary care setting.Objective To describe primary care clinicians' reports of missing clinical information.Design, Setting, and Participants Cross-sectional survey conducted in 32 primary care clinics within State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of practice-based research networks participating in the Applied Strategies for Improving Patient Safety medical error reporting study. Two hundred fifty-three clinicians were surveyed about 1614 patient visits between May and December 2003. For every visit during 1 half-day session, each clinician completed a questionnaire about patient and visit characteristics and stated whether important clinical information had been missing. Clinician characteristics were also recorded.Main Outcome Measures Reports of missing clinical information frequency, type, and presumed location; perceived likelihood of adverse effects, delays in care, and additional services; and time spent looking for missing information. Multivariate analysis was conducted to assess the relationship of missing information to patient, visit, or clinician characteristics, adjusting for potential confounders and effects of clustering.Results Clinicians reported missing clinical information in 13.6% of visits; missing information included laboratory results (6.1% of all visits), letters/clictation (5.4%), radiology results (3.8%), history and physical examination (3.7%), and Medications (3.2%). Missing clinical information was frequently reported to be located outside their clinical system but within the United States (52.3%), to be at least somewhat likely to adversely affect patients (44%), and to potentially result in delayed care or additional services (59.5%). Significant time was reportedly spent unsuccessfully searching for missing clinical information (5-10 minutes, 25.6%; >10 minutes, 10.4%). After adjustment, reported missing clinical information was more likely when patients were recent immigrants (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-2.99), new patients (OR, 2.39; 95% Cl, 1.70-3.35), or had multiple medical problems compared with no problems (1 problem: OR, 1.09; 95% Cl, 0.69-1.73; 2-5 problems: OR, 1, 87; 95% Cl, 1.21-2.89; >5 problems: OR, 2.78; 95% Cl, 1.61-4.80). Missing clinical information was less likely in rural practices (OR, 0.52; 95% Cl, 0.29-0.92) and when individual clinicians reported having full electronic records (OR, 0.40; 95% Cl, 0.17-0.94).Conclusions Primary care clinicians report that missing clinical information is common, multifaceted, likely to consume time and other resources, and may adversely affect patients. Additional research on missing information is needed to focus on validating clinicians' perceptions and on conducting prospective studies of its causes and sequelae.