HealthPartners Research Foundation, HealthPartners Medical Group, PO Box 1524, MS #21111R, Minneapolis, MN 55440-1524, USA.
Am J Manag Care. 2010 Feb;16(2):102-6.
OBJECTIVE: To evaluate the effects of providing appropriateness criteria through guideline-based electronic health record (EHR) decision support for high-tech diagnostic imaging (HTDI) procedures. STUDY DESIGN: Chart audits were performed on a random sample of adult primary care orders for 3 HTDI procedures (computed tomography [CT] and magnetic resonance imaging [MRI] of the head, and MRI of the lumbar spine) before and after implementation of an EHR decision support system. OUTCOME MEASURES: Level of appropriateness, abnormal findings, and apparent effects on patient care. RESULTS: A total of 299 eligible audits were performed. Decision support was associated with a 20% to 36% drop in spine MRI and head CT orders, but head MRI order volume was unaffected. Combined results for the 3 procedures showed that a larger proportion of studies ordered after implementing decision support (89.2% vs 79.5%, P = .02) fit appropriateness criteria, and more postimplementation studies had A ratings (highest utility rating) (81.8% vs 70%, P = .04). However, there were no differences in the proportion of tests with positive findings (42/132 vs 28/120, P = .16 among procedures that met definite criteria) or the proportion with a likely impact on patients (6.6% vs 10.8%, P = .07). CONCLUSIONS: These data support the feasibility of using chart audits to assess the relationship between appropriateness criteria and HTDI orders. Although introduction of EHR clinical decision support for diagnostic imaging orders was associated with reduced volume and increased appropriateness of orders, there was little apparent impact on either findings or patients.
目的:评估通过基于指南的电子健康记录(EHR)决策支持为高科技诊断成像(HTDI)程序提供适宜性标准的效果。
研究设计:在实施 EHR 决策支持系统之前和之后,对随机抽取的成人初级保健医嘱中进行的 3 种 HTDI 程序(头部 CT 和 MRI,以及腰椎 MRI)进行图表审核。
结果测量:适宜性水平、异常发现以及对患者护理的明显影响。
结果:共进行了 299 次合格审核。决策支持与脊柱 MRI 和头部 CT 订单减少 20%至 36%相关,但头部 MRI 订单量不受影响。3 种程序的综合结果表明,实施决策支持后,更多的研究符合适宜性标准(89.2%比 79.5%,P =.02),并且更多的后续研究具有 A 级评分(最高效用评分)(81.8%比 70%,P =.04)。然而,符合明确标准的测试中阳性发现的比例(42/132 比 28/120,P =.16)或对患者可能产生影响的比例(6.6%比 10.8%,P =.07)没有差异。
结论:这些数据支持使用图表审核评估适宜性标准与 HTDI 订单之间关系的可行性。尽管引入 EHR 临床决策支持来诊断成像订单与订单量减少和适宜性提高有关,但对发现或患者的影响微乎其微。
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