消失的文本作为临床决策支持层:一个案例系列
Jared Silberlust1, William Small2, Darshi Shah
1NYU Langone Health, New York, United States.
Applied clinical informatics
|August 5, 2025
概括
消失的文本 (DT) 临床决策支持 (CDS) 工具改善了IV抗生素和先进的护理规划的文档,当与其他CDS方法相结合时. 单独使用DT并没有显著改善抗凝血计划文件.
科学领域:
- 临床信息学 临床信息学
- 卫生信息技术 信息技术
- 医疗文件 医疗文件
背景情况:
- 临床决策支持 (CDS) 工具旨在提高医疗保健的质量和效率.
- 在线消失文本 (DT) 是一种CDS,在电子健康记录中提供提示.
- 评估不同DT配置的有效性对于优化其使用至关重要.
研究的目的:
- 评估线内消失文本 (DT) 临床决策支持 (CDS) 工具对临床医生文档的影响.
- 为了比较单独的DT与与其他CDS干预相结合的DT的有效性 (SmartList,OurPractice Advisory).
- 评估术后抗凝剂,预出院IV抗生素和高级护理规划的文档化率.
主要方法:
- 使用案例系列设计来评估DT实施的三个场景.
- 场景1:DT用于外科手术期间的抗凝计划.
- 场景2:使用SmartList进行DT,以便在出院前进行IV抗生素规划.
- 场景3:DT使用SmartList和OurPractice咨询来进行高级护理规划.
- 使用千平方分析,比较了干预前和干预后的记录率.
主要成果:
- 在外科手术期间的抗凝计划文件中没有显著变化 (情景1).
- 当DT与SmartList (情景2) 配对时,预出院IV抗生素规划文件的显著增加 (60%至93%,p < 0.001).
- 当DT与SmartList和咨询 (情景3) 结合时,高级护理规划笔记文档的显著增加 (43%至52%,p < 0.001).
结论:
- 将消失文本 (DT) 与其他临床决策支持 (CDS) 工具相结合,显著改善了预出院IV抗生素和高级护理规划的文档.
- 仅仅消失的文本 (DT) 没有显著影响到外科手术期间的抗凝计划文件.
- 社会技术因素可能会影响数据技术的有效性,这表明需要考虑技术,人员,工作流程和文化,以实现最佳实施.
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