自动历史记录软件对心脏病门诊数据质量的影响:回顾性观察性研究
Ismail Erden1, Arda Sen2, Ibrahim Emre Erden2
1Department of Cardiology, Atlas University Medical Faculty Medicine Hospital, Istanbul, Turkey.
Digital health
|June 4, 2024
概括
使用心血管检查自动评估 (AACE) 算法的新型患者提供者门户网站产生比医生文档更高质量的电子健康记录 (EHR). 这提高了心血管诊所的效率和患者护理.
科学领域:
- 心脏病学 心脏病学
- 医疗信息学 医疗信息学
- 医疗技术 医疗技术 医学技术
背景情况:
- 目前的医疗保健提供模式面临的挑战是,患者访问时间缩短,数据输入需求增加,影响患者与提供者的互动.
- 改善对先前测试结果和准确药物历史的访问对于提高医疗保健服务质量至关重要.
研究的目的:
- 评估一种新型患者-提供者门户,心血管检查自动化评估 (AACE) 的有效性,以提高电子健康记录 (EHR) 的质量.
- 来自AACE系统的计算机生成EHR的质量与医生在临床环境中记录的质量进行比较.
主要方法:
- 在成人心血管门诊诊所进行了一项采用配对样本设计的横截面研究.
- 患者在常规护理之前完成了AACE系统. 使用了两个协议:一个是没有医生访问AACE表格的,另一个是医生在检查前访问.
- 该研究评估了AACE生成的表单对检查效率,临床结果和患者满意度的影响.
主要成果:
- 总共有762名患者被纳入两个协议. 计算机生成的AACE电子病历获得的总体印象得分 (4.2) 与医生记录的电子病历 (2.6;p < .001) 相比,显著更高.
- 医生记录的电子健康记录显示出不准确和缺陷. 在医生审查AACE表格的协议中,检查时间减少,订购测试和新处方数量减少.
结论:
- 使用AACE算法的患者提供者门户网站生成了与医生文档相比,在质量,全面性,组织性和相关性方面优越的电子健康记录.
- 实施AACE可以提高效率,并可能减少心血管保健机构不必要的干预.
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