Future of Electronic Health Records: Implications for Decision Support
Future of Electronic Health Records: Implications for Decision Support
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DOI：
10.1002/msj.21351
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发表时间：
2012-11-01
影响因子：
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通讯作者：
Vigoda, Michael M.
中科院分区：
文献类型：
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作者：
Rothman, Brian;Leonard, Joan C.;Vigoda, Michael M.
与传统纸张相比，电子健康记录的潜在好处有很多，包括控制成本、减少错误以及通过利用实时数据提高合规性。电子健康记录 (EHR) 的最高功能级别是临床决策支持 (CDS) 和流程自动化，预计将增强患者的健康和医疗保健。作者概述了通过临床决策支持更高效地使用患者数据来改善医疗保健服务的进展，决策支持如何影响麻醉实践，以及一些人如何带头使用这些系统来解决特定需求的问题。临床决策支持使用被动或主动决策支持，通过具体行动的建议来改变临床医生的行为。建议可以减少用药错误，从而避免药物不良事件，从而节省大量费用。在选定的研究中，临床决策支持已被证明可以减少后续行动的时间，而预测已被证明有助于预测患者的结果、避免成本以及在参与决策之前正确提示临床医生修改治疗计划。电子健康记录提高了临床记录的准确性和完整性，并提供了更大的护理数据相关性。临床决策支持可以提高临床医生对临床指南的遵守程度，但教育研讨会可能同样有效。临床决策支持的意外后果（例如警报脱敏）可能会降低系统的有效性。目前的麻醉临床决策支持使用包括抗生素给药时机、改进的记录、更及时的计费以及术后恶心和呕吐的预防。电子健康记录的实施提供了数据挖掘的机会，以改善运营、财务和临床流程。实时使用电子健康记录数据进行决策支持和流程自动化有可能降低成本并提高患者护理质量。西奈山医学杂志 79:757768, 2012。(C) 2012 西奈山医学院
The potential benefits of the electronic health record over traditional paper are many, including cost containment, reductions in errors, and improved compliance by utilizing real-time data. The highest functional level of the electronic health record (EHR) is clinical decision support (CDS) and process automation, which are expected to enhance patient health and healthcare. The authors provide an overview of the progress in using patient data more efficiently and effectively through clinical decision support to improve health care delivery, how decision support impacts anesthesia practice, and how some are leading the way using these systems to solve need-specific issues. Clinical decision support uses passive or active decision support to modify clinician behavior through recommendations of specific actions. Recommendations may reduce medication errors, which would result in considerable savings by avoiding adverse drug events. In selected studies, clinical decision support has been shown to decrease the time to follow-up actions, and prediction has proved useful in forecasting patient outcomes, avoiding costs, and correctly prompting treatment plan modifications by clinicians before engaging in decision-making. Clinical documentation accuracy and completeness is improved by an electronic health record and greater relevance of care data is delivered. Clinical decision support may increase clinician adherence to clinical guidelines, but educational workshops may be equally effective. Unintentional consequences of clinical decision support, such as alert desensitization, can decrease the effectiveness of a system. Current anesthesia clinical decision support use includes antibiotic administration timing, improved documentation, more timely billing, and postoperative nausea and vomiting prophylaxis. Electronic health record implementation offers data-mining opportunities to improve operational, financial, and clinical processes. Using electronic health record data in real-time for decision support and process automation has the potential to both reduce costs and improve the quality of patient care. Mt Sinai J Med 79:757768, 2012. (C) 2012 Mount Sinai School of Medicine