Wilcox Adam B, Jones Spencer S, Dorr David A, Cannon Wayne, Burns Laurie, Radican Kelli, Christensen Kent, Brunker Cherie, Larsen Ann, Narus Scott P, Thornton Sidney N, Clayton Paul D
Intermountain Health Care, Salt Lake City, UT, USA.
AMIA Annu Symp Proc. 2005;2005:824-8.
Advanced clinical information systems have been proposed to improve patient care in terms of safety, effectiveness, and efficiency. In order to be effective, such systems require detailed patient-specific clinical information in a form easily reviewed by clinicians. We have developed a patient summary worksheet for use in outpatient clinics, which presents a structured overview of patient health information. The worksheet provides patient demographic information, specific problems and conditions, the patient's current medication profile, laboratory test results pertinent to patient problems, and disease-specific or preventive care actionable advisories. Usage has grown from a few hundred to over 25,000 unique patients per month during a two-year period. Diabetic patients for whom the worksheet is accessed are significantly more likely to be in compliance with accepted testing regimens for glycosolated hemoglobin (OR 1.47, 95% CI 1.28, 1.61).
先进的临床信息系统已被提出来，以在安全性、有效性和效率方面改善患者护理。为了有效，此类系统需要以临床医生易于查看的形式提供详细的患者特定临床信息。我们开发了一种用于门诊诊所的患者摘要工作表，它呈现了患者健康信息的结构化概述。该工作表提供患者人口统计学信息、特定问题和病症、患者当前的用药情况、与患者问题相关的实验室检查结果，以及针对特定疾病或预防性护理的可行建议。在两年时间里，其使用量从每月几百名独特患者增加到超过25000名。访问该工作表的糖尿病患者更有可能遵守糖化血红蛋白的公认检测方案（比值比1.47，95%置信区间1.28，1.61）。
