在电子健康记录中比较患者报告的症状和结构化的临床医生文档
Victor M Castro1,2, Vivian S Gainer2, Danielle M Crookes1
1Department of Public Health and Health Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, MA, 02115, United States.
概括
患者报告症状的频率是临床医生在电子健康记录 (EHR) 中记录的十倍. 将患者报告的症状 (PRS) 纳入真实世界数据 (RWD) 研究可以改善健康结果的捕捉.
科学领域:
- 医疗信息学 医疗信息学
- 临床研究 临床研究
- 患者报告的结果
背景情况:
- 现实世界数据 (RWD) 分析通常依赖于结构化的临床文档.
- 患者报告的结果测量 (PROM) 为RWD研究提供了宝贵的患者视角.
- 将PROM集成到电子健康记录 (EHR) 中可以提高对健康结果的理解.
研究的目的:
- 评估患者报告的症状 (PRS) 与临床医生记录的症状在电子健康记录中的一致性.
- 描述患者和临床医生之间症状报告中的差异.
- 评估在RWD中使用PROM用于全面健康捕获的可行性.
主要方法:
- 对913244名成年人初级保健访问 (2019-2023) 的横截面研究.
- 对15个症状类别的PRS和结构化临床医生文档 (CD) 的流行率和一致性进行比较.
- 分析包括呼吸,胃肠道,心脏代谢和神经精神症状.
主要成果:
- 患者报告的症状患病率明显高于临床医生对大多数症状 (例如,关节疼痛,头痛,睡眠障碍) 的记录.
- 临床医生记录的焦虑和抑郁的比患者报告的更高.
- 患者自我报告和临床医生文档之间的一致性低至中度 (κ: 0.06-0.39).
结论:
- 患者自我报告症状的频率远高于临床医生在电子健康记录中记录的频率.
- 将PRS纳入RWD研究可以减少错误分类,并提供对患者健康的更全面的看法.
- 这种方法提高了RWD在临床研究中的价值和可行性.
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