Leveraging Electronic Health Records for Guideline-Based Asthma Documentation.
Leveraging Electronic Health Records for Guideline-Based Asthma Documentation.
复制标题
利用电子健康记录进行基于指南的哮喘记录。
DOI：
10.1016/j.jaip.2022.11.032
复制
发表时间：
2023
期刊：
影响因子：
--
通讯作者：
Tantisira,Kelan
中科院分区：
文献类型：
--
作者：
Landeo-Gutierrez,Jeremy;Defante,Andrew;Cernelc-Kohan,Matejka;Akong,Kathryn;Rao,Aparna;Lesser,Daniel;Duong,ThuElizabeth;Cheng,EulaliaRY;Ryu,Julie;Tantisira,Kelan
背景哮喘是最常见的儿科慢性疾病，因此，临床指南已经制定了其评估和管理，这依赖于系统的症状记录。电子健康记录（EHR）具有系统记录临床数据的潜力;但是，在此情况下，目的确定与使用非结构化模板相比，使用结构化哮喘模板是否与增加基于指南的哮喘文档和临床结局相关。在2016年3月至2021年12月期间，由儿科肺科医生评估的新患者和首次随访中的结构化模板（AST）。根据临床指南选择哮喘史项目，总结为29项新的和22项随访遇到的。与人口统计学，肺功能测定，和医疗保健利用率的协会进行了explored.ResultsA共546首次遭遇包括450使用结构化模板。AST的使用与初始和随访中哮喘项目的较高记录相关。线性回归分析显示，与使用NST相比，使用AST与哮喘病史完整性增加28.2%和39.65%相关（分别在初始和随访中）。AST使用与12个月内全身性类固醇处方率较高相关。调整哮喘severity.ConclusionsUsing哮喘特异性结构化模板与增加基于指南的哮喘文档相关。利用EHR作为临床和研究工具有可能改善临床实践。
BackgroundAsthma is the most common pediatric chronic disease; thus, clinical guidelines have been developed for its assessment and management, which rely on systematic symptom documentation. Electronic health records (EHR) have the potential to record clinical data systematically; however, variability in documentation persists.ObjectiveTo identify if the use of a structured asthma template is associated with increased guideline-based asthma documentation and clinical outcomes when compared with the use of nonstructured ones.MethodsWe performed a retrospective case-control study comparing the use of nonstructured templates (NSTs) and asthma-structured templates (ASTs) in new patient and first follow-up encounters, evaluated by pediatric pulmonologists between March 2016 and December 2021. Asthma history items were selected following clinical guidelines, summarized in 29 items for new and 22 items for follow-up encounters. Associations with demographic, spirometry, and health care utilization were explored.ResultsA total of 546 initial encounters were included; 450 used structured templates. The use of an AST was associated with higher documentation of asthma items in initial and follow-up encounters. Linear regression analysis showed that the use of ASTs was associated with a 28.2% and 39.65% increase in asthma history completeness (in initial and follow-up encounters, respectively), compared with the use of NSTs. AST use was associated with higher rates of systemic steroid prescriptions within 12 months. No other differences were observed after adjusting for asthma severity.ConclusionsUsing asthma-specific structured templates was associated with increased guideline-based asthma documentation. Leveraging the EHR as a clinical and research tool has the potential to improve clinical practice.