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全科医生使用计算机进行处方开具和电子健康记录:一项全国性调查的结果。

General practitioners' use of computers for prescribing and electronic health records: results from a national survey.

作者信息

McInnes D Keith, Saltman Deborah C, Kidd Michael R

机构信息

Department of Health Care Policy, Harvard Medical School, Boston, MA, USA. mcinnesAThcp.med.harvard.edu

出版信息

Med J Aust. 2006 Jul 17;185(2):88-91. doi: 10.5694/j.1326-5377.2006.tb00479.x.

Abstract

OBJECTIVE

To describe how general practitioners use computers for clinical purposes.

DESIGN

Mail survey of a cross-sectional national stratified random sample of 3000 GPs in primary care settings between 10 October and 31 December 2005.

MAIN OUTCOME MEASURES

Use of computers, and use of computerised clinical functions such as prescribing, medication checking, generating health summaries, running recall systems, and writing progress notes.

RESULTS

Of 1186 GPs responding (39.5% response rate), 90% used a clinical software package. GPs used clinical packages for prescribing (98%), checking for drug-drug interactions (88%), recording a reason for prescribing (65%), to order laboratory tests (85%), run recall systems (78%), and record progress notes (64%). Less frequently used functions included generating lists of patients needing vaccines (43%) and taking the same medication (39%). Less than 20% of GPs who used a clinical package accessed computerised information during the consultation.

CONCLUSIONS

Australian general practice has achieved near-universal clinical computerisation. Electronic prescribing alone has probably improved efficiency and quality of care, and reduced medication errors. Increasing the use of other functions, such as accessing online decision support and maintaining registries of patients, is likely to lead to further health gains, especially in managing chronic conditions.

摘要

目的

描述全科医生如何将计算机用于临床目的。

设计

对2005年10月10日至12月31日期间在基层医疗环境中选取的3000名全科医生进行全国分层随机抽样的邮件调查。

主要观察指标

计算机的使用情况,以及计算机化临床功能的使用情况,如开处方、药物核对、生成健康摘要、运行召回系统和撰写病程记录。

结果

在1186名回复的全科医生中(回复率为39.5%),90%使用临床软件包。全科医生使用临床软件包进行开处方(98%)、检查药物相互作用(88%)、记录开处方原因(65%)、安排实验室检查(85%)、运行召回系统(78%)和记录病程记录(64%)。较少使用的功能包括生成需要接种疫苗的患者名单(43%)和服用相同药物的患者名单(39%)。在咨询过程中,使用临床软件包的全科医生中不到20%会获取计算机化信息。

结论

澳大利亚的全科医疗已实现近乎全面的临床计算机化。仅电子处方就可能提高了医疗效率和质量,并减少了用药错误。增加对其他功能的使用,如获取在线决策支持和维护患者登记册,可能会带来进一步的健康益处,尤其是在慢性病管理方面。

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