Impact of problem-based charting on the utilization and accuracy of the electronic problem list
Impact of problem-based charting on the utilization and accuracy of the electronic problem list
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DOI：
10.1093/jamia/ocx154
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发表时间：
2018-05-01
影响因子：
6.4
通讯作者：
Chen, Jonathan H.
中科院分区：
文献类型：
--
作者：
Li, Ron C.;Garg, Trit;Chen, Jonathan H.
目的：基于问题的图表（PBC）是一种在市售电子病历系统中集成笔记书写和问题清单管理的临床医生记录方法。我们报告了PBC对学术重症监护室（ICU）问题清单利用率和准确性的影响。材料和方法：采用中断时间序列设计来评估PBC对问题清单利用率的影响，问题清单利用率被定义为临床医生每个患者遇到的新问题添加到问题清单的数量，以及问题清单准确性，通过计算问题清单在捕获5种常见ICU诊断中的召回率和精度来确定。结果：在斯坦福医院实施PBC前后，共确定了3650例和4344例患者记录。每位患者遇到的问题列表中新增问题的平均数量增加了2.18个问题（增加了50%），这可归因于PBC的开始。在脓毒症（β = 0.45, P < 0.001）和急性肾功能衰竭（β = 0.2, P = 0.007）开始使用PBC时，召回率显著增加，但在急性呼吸衰竭、肺炎或静脉血栓栓塞时没有。讨论：问题列表是电子病历中未充分利用的组成部分，它可以作为临床医生结构化数据的来源，实时表示患者的临床状况。PBC是一种现成的工具，可以将问题列表管理集成到医生工作流程中。结论：PBC提高了学术ICU问题清单的使用率和准确性。
Objective: Problem-based charting (PBC) is a method for clinician documentation in commercially available electronic medical record systems that integrates note writing and problem list management. We report the effect of PBC on problem list utilization and accuracy at an academic intensive care unit (ICU).Materials and Methods: An interrupted time series design was used to assess the effect of PBC on problem list utilization, which is defined as the number of new problems added to the problem list by clinicians per patient encounter, and of problem list accuracy, which was determined by calculating the recall and precision of the problem list in capturing 5 common ICU diagnoses.Results: In total, 3650 and 4344 patient records were identified before and after PBC implementation at Stanford Hospital. An increase of 2.18 problems (>50% increase) in the mean number of new problems added to the problem list per patient encounter can be attributed to the initiation of PBC. There was a significant increase in recall attributed to the initiation of PBC for sepsis (beta = 0.45, P < .001) and acute renal failure (beta = 0.2, P = .007), but not for acute respiratory failure, pneumonia, or venous thromboembolism.Discussion: The problem list is an underutilized component of the electronic medical record that can be a source of clinician-structured data representing the patient's clinical condition in real time. PBC is a readily available tool that can integrate problem list management into physician workflow.Conclusion: PBC improved problem list utilization and accuracy at an academic ICU.