コンピューター化された医療記録の要約システムは,標準的な医療記録よりも多くの情報を提供することができます
JAMA
|September 6, 1985
まとめ
コンピュータ化された医療記録システム (STOR) は,外科医の関節炎診療所で患者の結果を予測する医師の能力を向上させました. STORは情報フローを向上させ,臨床意思決定プロセスを改善する可能性がある.
科学分野:
- 医療情報工学 医療情報工学
- 臨床的意思決定支援について
背景:
- 患者の情報の効果的な伝達は,診療室外での臨床的意思決定に不可欠です.
- 伝統的な紙ベースの医療記録 (MR) は,情報のアクセシビリティと合成に制限がある可能性があります.
研究 の 目的:
- コンピューター化された医療記録システムである,時間指向の要約記録 (STOR) が,臨床医が患者の情報にアクセスし,利用する能力に与える影響を評価する.
- 標準MRのみと比較して,STORが情報伝達を強化するかどうかを評価する.
主な方法:
- 2つのランダム化単盲試験が実施され,関節炎の診療所に外来患者による訪問が実施されました.
- 研究1では,標準MRと標準MR+STORによる医師の予測能力を比較した.
- 研究2では,STORアクセスで医師の予測能力を検証し,完全な紙の記録を閲覧するオプションがありました.
主要な成果:
- 医師は,標準MRにSTORを追加したときに,患者の症状の変化と検査結果の予測が改善されたことを実証しました.
- 標準MRの削除は,医師が必要に応じて完全な紙の記録にアクセスできれば (26%の訪問で使用された) 予測能力を有意に低下させなかった.
- コンピュータ化されたSTORシステムは,診察室の外科医の診察のための標準的な紙のMRを超える貴重な情報を操作的に追加しました.
結論:
- 概要時間指向記録 (STOR) システムは,外来診察の際の臨床情報の流れを向上させます.
- STORのようなコンピュータ化されたシステムによる情報アクセシビリティの改善は,臨床意思決定プロセスに肯定的な影響を及ぼす可能性があります.
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