使用结构化模板来提高内分泌学推的完整性
Kevin A Arao1, Denise H Wong2, Jolie B Wormwood3
1Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, Massachusetts; Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts.
概括
结构化推模板显著提高了内分泌学推的完整性,平均为41%. 这项质量改善计划增强了基本的临床信息,有利于患者的护理.
科学领域:
- 改善医疗保健的质量
- 医疗信息学 医疗信息学
- 内分泌学 在内分泌学.
背景情况:
- 对内分泌学的转诊往往缺乏关键的临床数据,可能导致效率低下和负面的患者结果.
- 启动了一项质量改进项目,以解决退伍军人卫生管理局医疗中心的不完整内分泌学转诊问题.
研究的目的:
- 通过使用结构化推模板,提高新的内分泌学推的完整性.
- 在常见的内分泌疾病中,至少提高30%的转诊完整性.
主要方法:
- 开发了电子结构推模板,并从初级保健提供者和内分泌学家那里获得了投入.
- 进行了回顾性图表审查,比较了125个干预前和125个干预后的转诊.
- 使用基于基本要素的评分系统来评估推的完整性.
主要成果:
- 平均转诊完整度从干预前的52%,增加到干预后的93%.
- 所有条件都达到了30%的改善目标;最大的改善是"访问偏好类型".
- 除了"访问喜好类型",完整性从64%提高到92%.
结论:
- 集成到电子系统中的结构化推模板可以显著提高内分泌学推的质量和完整性.
- 未来的研究应该评估这些模板对临床效率,患者体验和结果的影响.
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