Structured vs. unstructured: factors affecting adverse drug reaction documentation in an EMR repository.
Structured vs. unstructured: factors affecting adverse drug reaction documentation in an EMR repository.
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发表时间：
2011
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通讯作者：
S. Skentzos;M. Shubina;J. Plutzky;A. Turchin
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作者：
S. Skentzos;M. Shubina;J. Plutzky;A. Turchin
对已知患者不耐受的药物的不良反应很常见。电子决策支持可以预防它们，但前提是以结构化格式记录药物不良反应历史。我们对 31,531 名在笔记中记录有他汀类药物不良反应的患者进行了一项回顾性研究，这些不良反应是通过自然语言处理识别的。该软件识别他汀类药物不良反应的敏感性为 86.5%，精确度为 91.9%。其中只有 9020 名患者对以结构化格式记录的他汀类药物有不良反应。在多变量分析中，结构化文档的最强预测因素是 EMR 功能的利用，该功能将药物列表与结构化药物不良反应存储库集成在一起（比值比 48.6，p < 0.0001）。 EMR 模块之间的信息流集成有助于改进文档记录并有可能预防药物不良事件。
Adverse reactions to medications to which the patient was known to be intolerant are common. Electronic decision support can prevent them but only if history of adverse reactions to medications is recorded in structured format. We have conducted a retrospective study of 31,531 patients with adverse reactions to statins documented in the notes, as identified with natural language processing. The software identified statin adverse reactions with sensitivity of 86.5% and precision of 91.9%. Only 9020 of these patients had an adverse reaction to a statin recorded in structured format. In multivariable analysis the strongest predictor of structured documentation was utilization of EMR functionality that integrated the medication list with the structured medication adverse reaction repository (odds ratio 48.6, p < 0.0001). Integration of information flow between EMR modules can help improve documentation and potentially prevent adverse drug events.