Rubber stamp templates for improving clinical documentation: A paper-based, m-Health approach for quality improvement in low-resource settings.
Rubber stamp templates for improving clinical documentation: A paper-based, m-Health approach for quality improvement in low-resource settings.
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DOI：
10.1016/j.ijmedinf.2017.10.014
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发表时间：
2018-06
影响因子：
4.9
通讯作者：
Kumar P
中科院分区：
文献类型：
--
作者：
Kleczka B;Musiega A;Rabut G;Wekesa P;Mwaniki P;Marx M;Kumar P
联合国可持续发展目标#3.8 的目标是“获得优质的基本医疗保健服务”。临床实践指南是确保临床护理质量的重要工具，但许多挑战阻碍其在资源匮乏的环境中使用。监测指南的使用依赖于对纸质记录进行繁琐的临床审核，而电子系统面临财务和其他限制。在这里，我们描述了一种使用基于指南的模板、橡皮图章和手机从纸张生成数字数据的独特方法。贫民窟遵守指南项目的目标是为肯尼亚内罗毕的非正规住区提供服务的十家私营部门初级医疗保健诊所。每个诊所都提供了橡皮图章模板，以支持常见门诊情况的记录和管理。使用参与式设计方法来定制每个诊所的工作流程和基础设施的模板。使用橡皮图章将模板打印成纸质图表，为临床医生提供在咨询期间使用的清单。模板使用气泡格式数据输入，可以将手机拍摄的图像数字化。除了橡皮图章模板外，干预措施还包括指南汇编小册子、一部用于数字化模板图像的 Android 手机以及每个诊所每月一次的数据反馈/继续医学教育课程。在本文中，我们重点关注干预措施对一家诊所三种非传染性疾病记录的影响。对 10 个干预诊所之一参加慢性病项目（高血压/糖尿病，n = 867；慢性呼吸道疾病，n = 223）的 70 名患者进行了抽样。对每个患者在干预前（2016 年 1 月至 3 月）和干预后（5 月至 7 月）期间遭遇的记录进行评分，以获取四个维度的信息：一般数据、患者评估、测试和管理。控制标准包括模板中没有对应内容的信息（例如，有关提出投诉、生命体征的注释）。比较干预前和干预后期间以及使用和不使用模板记录的遭遇之间（仅干预后）每个患者的记录评分。干预前（282 例）和干预后（264 例）接触患者的总数没有差异。干预后，高血压、糖尿病和慢性呼吸道疾病的平均记录分数平均分别显着提高了 21%、24% 和 17%。比较有模板和没有模板的文档时，差异更大（分别为 47%、43% 和 27%）。干预前与干预后、有模板与无模板之间的变化因文档的各个维度而异。总体而言，一般数据和患者评估的文档记录比测试或管理的记录改善更多。模板的使用改进了患者护理的纸质文档，这是提高护理质量的第一步。橡皮图章提供了一种简单且低成本的按需打印模板的方法。与无处不在的移动电话相结合，纸质输入的信息可以轻松快速地数字化。移动医疗领域的这种“节俭创新”可以使大量城市患者寻求医疗保健的小型私营机构能够生成常规门诊护理的数字数据。这些数据可以为大规模的循证质量改进工作奠定基础，并有助于兑现为所有人提供优质基本医疗服务的可持续发展目标承诺。
The United Nations’ Sustainable Development Goal #3.8 targets ‘access to quality essential healthcare services’. Clinical practice guidelines are an important tool for ensuring quality of clinical care, but many challenges prevent their use in low-resource settings. Monitoring the use of guidelines relies on cumbersome clinical audits of paper records, and electronic systems face financial and other limitations. Here we describe a unique approach to generating digital data from paper using guideline-based templates, rubber stamps and mobile phones. The Guidelines Adherence in Slums Project targeted ten private sector primary healthcare clinics serving informal settlements in Nairobi, Kenya. Each clinic was provided with rubber stamp templates to support documentation and management of commonly encountered outpatient conditions. Participatory design methods were used to customize templates to the workflows and infrastructure of each clinic. Rubber stamps were used to print templates into paper charts, providing clinicians with checklists for use during consultations. Templates used bubble format data entry, which could be digitized from images taken on mobile phones. Besides rubber stamp templates, the intervention included booklets of guideline compilations, one Android phone for digitizing images of templates, and one data feedback/continuing medical education session per clinic each month. In this paper we focus on the effect of the intervention on documentation of three non-communicable diseases in one clinic. Seventy charts of patients enrolled in the chronic disease program (hypertension/diabetes, n = 867; chronic respiratory diseases, n = 223) at one of the ten intervention clinics were sampled. Documentation of each individual patient encounter in the pre-intervention (January–March 2016) and post-intervention period (May–July) was scored for information in four dimensions – general data, patient assessment, testing, and management. Control criteria included information with no counterparts in templates (e.g. notes on presenting complaints, vital signs). Documentation scores for each patient were compared between both pre- and post-intervention periods and between encounters documented with and without templates (post-intervention only). The total number of patient encounters in the pre-intervention (282) and post-intervention periods (264) did not differ. Mean documentation scores increased significantly in the post-intervention period on average by 21%, 24% and 17% for hypertension, diabetes and chronic respiratory diseases, respectively. Differences were greater (47%, 43% and 27%, respectively) when documentation with and without templates was compared. Changes between pre- vs.post-intervention, and with vs.without template, varied between individual dimensions of documentation. Overall, documentation improved more for general data and patient assessment than in testing or management. The use of templates improves paper-based documentation of patient care, a first step towards improving the quality of care. Rubber stamps provide a simple and low-cost method to print templates on demand. In combination with ubiquitously available mobile phones, information entered on paper can be easily and rapidly digitized. This ‘frugal innovation’ in m-Health can empower small, private sector facilities, where large numbers of urban patients seek healthcare, to generate digital data on routine outpatient care. These data can form the basis for evidence-based quality improvement efforts at large scale, and help deliver on the SDG promise of quality essential healthcare services for all.
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