Problem list completeness in electronic health records: A multi-site study and assessment of success factors
Problem list completeness in electronic health records: A multi-site study and assessment of success factors
复制标题
DOI：
10.1016/j.ijmedinf.2015.06.011
复制
发表时间：
2015-10-01
影响因子：
4.9
通讯作者：
Sittig, Dean F.
中科院分区：
文献类型：
--
作者：
Wright, Adam;McCoy, Allison B.;Sittig, Dean F.
目的：为了评估问题清单的完整性，使用一个客观的措施在一系列的网站，并确定成功的因素问题清单completeness.Methods：我们进行了一个回顾性分析，电子健康记录数据和采访在美国，英国和阿根廷的10个医疗机构使用各种电子健康记录系统：4个自我开发和6个商业。在每个研究中心，我们评估了在所有血红蛋白A1c升高≥ 7.0%（诊断为糖尿病）的患者中，问题列表上记录的糖尿病患者的比例。然后，我们与四个表现最好的站点的信息学领导者进行了访谈，以确定与成功相关的因素。最后，我们调查了所有的网站关于常见的做法，在执行最好的网站，以确定是否有问题列表管理的做法和问题列表completeness.Results之间的关联：问题列表完整性在10个网站的范围从60.2%到99.4%，平均为78.2%。财务激励、以问题为导向的图表、差距报告、共同责任、与账单代码的链接和组织文化被确定为四家医院的成功因素，问题列表的完整性达到或接近90.0%。讨论：不完整的问题列表代表了一个全球性的数据完整性问题，可能会影响护理质量并使患者处于风险之中。在医疗机构中，问题列表的完整性范围很广。然而，一些设施已经实现了高水平的问题列表的完整性，它是很重要的是要更好地了解成功的因素，以提高病人safety.Conclusion：问题列表的完整性有很大的不同，在医疗机构。在我们对10个医疗机构的EHR系统进行的审查中，我们确定了六个成功因素，这些因素可能对寻求提高问题列表文档质量的医疗机构有用：财务激励，以问题为导向的图表，差距报告，共同责任，与计费代码的链接，以及组织文化。(C)2015爱思唯尔爱尔兰有限公司版权所有。
Objective: To assess problem list completeness using an objective measure across a range of sites, and to identify success factors for problem list completeness.Methods: We conducted a retrospective analysis of electronic health record data and interviews at ten healthcare organizations within the United States, United Kingdom, and Argentina who use a variety of electronic health record systems: four self-developed and six commercial. At each site, we assessed the proportion of patients who have diabetes recorded on their problem list out of all patients with a hemoglobin A1c elevation > = 7.0%, which is diagnostic of diabetes. We then conducted interviews with informatics leaders at the four highest performing sites to determine factors associated with success. Finally, we surveyed all the sites about common practices implemented at the top performing sites to determine whether there was an association between problem list management practices and problem list completeness.Results: Problem list completeness across the ten sites ranged from 60.2% to 99.4%, with a mean of 78.2%. Financial incentives, problem-oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture were identified as success factors at the four hospitals with problem list completeness at or near 90.0%.Discussion: Incomplete problem lists represent a global data integrity problem that could compromise quality of care and put patients at risk. There was a wide range of problem list completeness across the healthcare facilities. Nevertheless, some facilities have achieved high levels of problem list completeness, and it is important to better understand the factors that contribute to success to improve patient safety.Conclusion: Problem list completeness varies substantially across healthcare facilities. In our review of EHR systems at ten healthcare facilities, we identified six success factors which may be useful for healthcare organizations seeking to improve the quality of their problem list documentation: financial incentives, problem oriented charting, gap reporting, shared responsibility, links to billing codes, and organizational culture. (C) 2015 Elsevier Ireland Ltd. All rights reserved.