Electronic health records improve clinical note quality.
Electronic health records improve clinical note quality.
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DOI：
10.1136/amiajnl-2014-002726
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发表时间：
2015-01
期刊：
影响因子：
--
通讯作者：
Gimbel RW
中科院分区：
文献类型：
--
作者：
Burke HB;Sessums LL;Hoang A;Becher DA;Fontelo P;Liu F;Stephens M;Pangaro LN;O'Malley PG;Baxi NS;Bunt CW;Capaldi VF 2nd;Chen JM;Cooper BA;Djuric DA;Hodge JA;Kane S;Magee C;Makary ZR;Mallory RM;Miller T;Saperstein A;Servey J;Gimbel RW
背景与目的临床笔记记录了临床医生的信息收集、问题评估、临床管理及其用于行政目的。电子健康记录（EHR）正在美国各地的临床实践中实施，但尚不清楚它们是否提高了临床记录的质量。本研究的目的是确定电子病历是否能提高门诊病历的质量。材料与方法一项为期5年半的纵向回顾性多中心定量研究，比较了100例2型糖尿病患者在3个时间点的手写和电子门诊就诊记录的质量：引入EHR前6个月（前EHR），引入EHR后6个月（后EHR），和引入EHR后5年（5年EHR）。 QNOTE是一种经过验证的定量工具，用于评估门诊病历的质量。它的分数范围从最低的0到最高的100。16名积极执业的初级保健医生使用QNOTE来确定300份患者记录的质量。结果EHR治疗前、治疗后和5年EHR总平均评分（SD）分别为52.0（18.4）、61.2（16.3）和80.4（8.9），EHR治疗前与治疗后和治疗前与5年EHR评分的变化分别为18%（p<0.0001）和55%（p<0.0001）。在5年时间间隔内，所有元素和总平均质量评分均显著改善。结论电子病历系统显著提高了门诊病历的整体质量和各要素的质量，包括核心要素和非核心要素。据我们所知，这是第一项证明EHR显著提高临床记录质量的研究。
Background and objective The clinical note documents the clinician's information collection, problem assessment, clinical management, and its used for administrative purposes. Electronic health records (EHRs) are being implemented in clinical practices throughout the USA yet it is not known whether they improve the quality of clinical notes. The goal in this study was to determine if EHRs improve the quality of outpatient clinical notes. Materials and methods A five and a half year longitudinal retrospective multicenter quantitative study comparing the quality of handwritten and electronic outpatient clinical visit notes for 100 patients with type 2 diabetes at three time points: 6 months prior to the introduction of the EHR (before-EHR), 6 months after the introduction of the EHR (after-EHR), and 5 years after the introduction of the EHR (5-year-EHR). QNOTE, a validated quantitative instrument, was used to assess the quality of outpatient clinical notes. Its scores can range from a low of 0 to a high of 100. Sixteen primary care physicians with active practices used QNOTE to determine the quality of the 300 patient notes. Results The before-EHR, after-EHR, and 5-year-EHR grand mean scores (SD) were 52.0 (18.4), 61.2 (16.3), and 80.4 (8.9), respectively, and the change in scores for before-EHR to after-EHR and before-EHR to 5-year-EHR were 18% (p<0.0001) and 55% (p<0.0001), respectively. All the element and grand mean quality scores significantly improved over the 5-year time interval. Conclusions The EHR significantly improved the overall quality of the outpatient clinical note and the quality of all its elements, including the core and non-core elements. To our knowledge, this is the first study to demonstrate that the EHR significantly improves the quality of clinical notes.
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2013-01-01
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