Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, Montreal, Qc, Canada.
BMC Med Inform Decis Mak. 2010 Feb 23;10:10. doi: 10.1186/1472-6947-10-10.
Health problem lists are a key component of electronic health records and are instrumental in the development of decision-support systems that encourage best practices and optimal patient safety. Most health problem lists require initial clinical information to be entered manually and few integrate information across care providers and institutions. This study assesses the accuracy of a novel approach to create an inter-institutional automated health problem list in a computerized medical record (MOXXI) that integrates three sources of information for an individual patient: diagnostic codes from medical services claims from all treating physicians, therapeutic indications from electronic prescriptions, and single-indication drugs.
Data for this study were obtained from 121 general practitioners and all medical services provided for 22,248 of their patients. At the opening of a patient's file, all health problems detected through medical service utilization or single-indication drug use were flagged to the physician in the MOXXI system. Each new arising health problem were presented as 'potential' and physicians were prompted to specify if the health problem was valid (Y) or not (N) or if they preferred to reassess its validity at a later time.
A total of 263,527 health problems, representing 891 unique problems, were identified for the group of 22,248 patients. Medical services claims contributed to the majority of problems identified (77%), followed by therapeutic indications from electronic prescriptions (14%), and single-indication drugs (9%). Physicians actively chose to assess 41.7% (n = 106,950) of health problems. Overall, 73% of the problems assessed were considered valid; 42% originated from medical service diagnostic codes, 11% from single indication drugs, and 47% from prescription indications. Twelve percent of problems identified through other treating physicians were considered valid compared to 28% identified through study physician claims.
Automation of an inter-institutional problem list added over half of all validated problems to the health problem list of which 12% were generated by conditions treated by other physicians. Automating the integration of existing information sources provides timely access to accurate and relevant health problem information. It may also accelerate the uptake and use of electronic medical record systems.
健康问题列表是电子健康记录的关键组成部分,对于开发鼓励最佳实践和优化患者安全的决策支持系统至关重要。大多数健康问题列表需要手动输入初始临床信息,并且很少将信息整合到各个护理提供者和机构中。本研究评估了一种新颖的方法在计算机化医疗记录(MOXXI)中创建机构间自动化健康问题列表的准确性,该方法整合了个体患者的三个信息源:来自所有治疗医生的医疗服务索赔的诊断代码、电子处方的治疗指征和单一指征药物。
本研究的数据来自 121 名全科医生和他们的 22248 名患者的所有医疗服务。在患者档案打开时,通过医疗服务利用或单一指征药物使用检测到的所有健康问题都在 MOXXI 系统中向医生标记。每个新出现的健康问题都被表示为“潜在”,医生被提示指定健康问题是否有效(Y)或无效(N),或者他们是否更愿意稍后重新评估其有效性。
共为 22248 名患者确定了 263527 个健康问题,代表 891 个独特的问题。医疗服务索赔为确定的大多数问题做出了贡献(77%),其次是电子处方的治疗指征(14%)和单一指征药物(9%)。医生主动选择评估 41.7%(n=106950)的健康问题。总体而言,73%的评估问题被认为有效;42%源于医疗服务诊断代码,11%源于单一指征药物,47%源于处方指征。通过其他治疗医生确定的 12%的问题被认为有效,而通过研究医生索赔确定的问题为 28%。
机构间问题列表的自动化为健康问题列表添加了超过一半的所有已验证问题,其中 12%是由其他医生治疗的病症产生的。自动化整合现有信息来源可及时获取准确和相关的健康问题信息。它还可能加速电子病历系统的采用和使用。