建立必要的临床数据元素,以在时间有限的环境中提供有效的治疗.
Yong Seo Koo1, Tae Young Kim1, Seo-Young Lee2
1Department of Neurology, Asan Medical Center, Seoul, South Korea.
Seizure
|March 20, 2025
概括
研究人员开发了治疗的核心共同数据元素 (CDE),提高了简短咨询的效率. 这些CDE标准化临床信息,以改善患者的治疗结果.
科学领域:
- 神经学 神经学
- 临床信息学 临床信息学
- 医疗保健服务研究 医疗服务研究
背景情况:
- 治疗需要持续收集数据以进行有效的管理.
- 临床环境中的时间限制往往限制了全面的患者评估.
- 标准化数据元素对于提高护理质量和效率至关重要.
研究的目的:
- 开发用于常规护理的共同数据元素 (CDE) 的核心集合.
- 提高临床管理的一致性和效率.
- 在短时间的咨询中创建可行的CDE,以集成电子健康记录 (EHR).
主要方法:
- 一种经过修改的Delphi方法被用于大学附属医院的病学家.
- 参与者在三轮调查中对拟议的CDE的可行性和重要性进行了评价.
- 在参与者反的指导下进行代改进,以开发笔记模板.
主要成果:
- 在68位受邀的病学家中,有61位参与 (89.7%的响应率).
- 达成共识,对6个CDE进行后续说明,20个CDE进行初始/定期评估.
- 观察到对CDE的必要性 (98%) 和预期实施 (97%) 的高度认可.
结论:
- 在韩国建立了一个实用,基于共识的核心CDE的框架,用于治疗.
- 这些CDE旨在提高护理的一致性和质量,特别是在时间限制下.
- 未来的工作包括扩大CDE,整合患者报告的结果,并嵌入EHR.
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