Cardiovascular Disease Care and EMR Use in Community-based Primary Care Practices

描述（由申请人提供）：广泛推荐在门诊环境中使用电子病历（EMRs），以提高患者护理的安全性、质量和效率。大多数证明电子病历有效性的研究来自四个示范机构，这些机构拥有在社区实践环境中通常无法获得的系统级资源和财政、教育和信息技术支持。然而，人们对EMRs在社区门诊环境中改善护理的有效性知之甚少，而美国的大多数初级保健都是在社区门诊环境中提供的。目的：我们的主要研究问题是：如何在社区初级保健实践中使用电子病历来护理患者以及使用模式如何与卫生保健质量相关？为了解决这个问题，将实现三个目标：目标1：描述电子病历如何在广泛的临床护理和非临床活动中普遍使用；目标2：描述电子病历如何在急慢性护理临床过程中具体使用；目标3：确定在社区初级保健实践中指导电子病历使用的策略。方法：本研究采用多方法（观察法、访谈法、调查法）收集数据，采用定性研究方法。研究参与者将是医生拥有的、使用电子病历的单一专业社区初级保健实践的实践成员，并参加了我们的ULTRA研究（N=16）。练习选择将是有目的的和迭代的。将随机选择前两个实践，并深入收集定性数据。同时，所有参与的医疗机构的成员将完成电子病历调查。该调查的数据将为后续的实践选择提供信息。该调查包括关于EMR使用和系统功能的项目，以及评估影响信息系统使用的人为因素的项目。EMR调查结果和来自前两个实践的定性数据将被分析，这些见解将为接下来两个实践的选择提供信息，以进行深入的数据收集和分析。将选择提供最大变化和学习机会的实践。有目的地选择实践、收集和分析数据以确定电子病历使用的重要决定因素的迭代过程将继续下去，直到达到饱和，即新病例不再提供与电子病历使用相关的新信息。我们预计这将在学习8个实践后发生。在这一点上，将选择两个额外的实践来确认/否定发现。数据分析：在国家专家的协助下，将使用一系列浸泡/结晶周期进行比较分析，以全面了解EMR在社区初级保健实践中的使用和护理组织。益处：本研究将确定社区初级保健实践如何使用电子病历来支持临床和非临床护理过程。研究结果将用于产生关于有效EMR使用的假设，以便在随后的R01中在具有代表性的实践样本中进行测试。这项工作为通过更有效地使用电子病历来改善临床护理的干预措施铺平了道路。公共卫生相关性：这项研究将是一个重要的贡献，扩展当前关于如何使用电子病历来支持基于社区的初级保健实践中的临床和非临床护理过程的知识。这项创新研究是通过在这种情况下更有效地使用电子病历来改善临床护理的研究项目的第一步。

DESCRIPTION (provided by applicant): The use of electronic medical records (EMRs) in ambulatory settings is widely recommended to improve the safety, quality and efficiency of patient care. Most research demonstrating the efficacy of EMRs comes from four exemplar institutions that have system level resources and support for financial, educational and information technology not commonly available in community practice settings. Less, however, is known about the effectiveness of EMRs for care improvement in community ambulatory settings where most primary care in the United States is delivered. Objective: Our principal research question is: How are EMRs used among community-based primary care practices to care for patients and how are use patterns related to health care quality? To address this question, three aims will be accomplished: Aim 1: To describe how EMRs are generally used in a broad range of clinical care and non-clinical activities; Aim 2: To describe how EMRs are specifically used in acute and chronic care clinical processes; and Aim 3: To identify strategies that guide EMR use in community-based primary care practices. Methods: This study involves collection of multi-method data (observation, interview, survey) and employs a qualitative research methodology. Study participants will be practice members at physician-owned, single specialty community primary care practices that use an EMR and participated in our ULTRA study (N=16). Practice selection will be purposeful and iterative. The first two practices will be randomly selected, and in depth qualitative data will be collected. At the same time, an EMR survey will be completed by members of all participating practices. Data from this survey will inform subsequent practice selection. The survey includes items about EMR use and system functionality, and items to evaluate human factors that shape information system use. EMR survey responses and qualitative data from the first two practices will be analyzed, and insights will inform the selection of the next two practices for in depth data collection and analysis. Practices will be selected that offer the opportunity to maximize variation and learning. The iterative process of purposefully selecting practices and collecting and analyzing data to identify the important determinants of EMR use will continue until saturation is reached - the point at which new cases provide no new information related to EMR use. We anticipate this will occur after studying 8 practices. At this point, two additional practices will be selected to confirm/disconfirm findings. Data Analysis: With the assistance of national experts, a comparative analysis will be conducted using a series of immersion/crystallization cycles to develop a comprehensive understanding of EMR use and the organization of care in community primary care practice. Benefits: This study will identify how community primary care practices use EMRs to support clinical and non-clinical care processes. Findings will be used to generate hypotheses about effective EMR use to be tested in a subsequent R01 among a representative sample of practices. This work paves the way for interventions to improve clinical care through more effective EMR use. Public Health Relevance: This study will be an important contribution, extending current knowledge of how EMRs are used to support clinical and non-clinical care processes in community-based primary care practices. This innovative study is the first step in a program of research to improve clinical care through more effective EMR use in this setting.