基于电子病历的纸质临床总结的创建和评估，以支持非洲乌干达的艾滋病护理。
Creation and evaluation of EMR-based paper clinical summaries to support HIV-care in Uganda, Africa.
机构信息
Regenstrief Institute, Inc., Indiana University School of Medicine, Indianapolis, IN, USA.
出版信息
Int J Med Inform. 2010 Feb;79(2):90-6. doi: 10.1016/j.ijmedinf.2009.11.006. Epub 2009 Dec 24.
PURPOSE
Getting the right information to providers can improve quality of care. We set out to provide patient-specific Electronic Medical Record (EMR)-based clinical summaries for providers taking care of HIV-positive adult patients in the resource-limited setting of Mbarara, Uganda.
METHODS
We evaluated the impact of implementing these clinical summaries using time-motion techniques and provider surveys.
RESULTS
After implementation of EMR-based clinical summaries, providers spent more time in direct care of patients (2.9 min vs. 2.3 min, p<0.001), and the length of patient visits was reduced by 11.5 min. Survey respondents indicated that clinical summaries improved care, reduced mistakes, and were generally accurate. Current antiretroviral medication, patient identifying information, adherence information, current medication, and current medical problems were among the highest-rated elements of the summary.
CONCLUSIONS
By taking advantage of data stored in EMRs, efficiency and quality of care can be improved through clinical summaries, even in settings with limited resources.
目的
为医务人员提供正确的信息可以提高医疗质量。我们旨在为乌干达姆巴拉拉资源有限的环境中照顾 HIV 阳性成年患者的医务人员提供基于电子病历（EMR）的患者特定临床总结。
方法
我们使用时间动作技术和医务人员调查评估实施这些临床总结的效果。
结果
在实施基于 EMR 的临床总结后，医务人员用于直接照顾患者的时间增加了（2.9 分钟比 2.3 分钟，p<0.001），患者就诊时间减少了 11.5 分钟。调查对象表示，临床总结改善了护理，减少了错误，且总体上是准确的。目前的抗逆转录病毒药物、患者识别信息、用药依从性信息、当前药物和当前医疗问题是总结中评价最高的内容。
结论
通过利用 EMR 中存储的数据，可以通过临床总结提高护理效率和质量，即使在资源有限的环境中也是如此。
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