Hahn Karissa A, Ohman-Strickland Pamela A, Cohen Deborah J, Piasecki Alicja K, Crosson Jesse C, Clark Elizabeth C, Crabtree Benjamin F
University of Medicine and Dentistry of New Jersey, Somerset, USA.
Am J Med Qual. 2011 Jul-Aug;26(4):272-7. doi: 10.1177/1062860610392365. Epub 2011 Jan 25.
The adoption of electronic medical records (EMRs) in ambulatory settings has been widely recommended. It is hoped that EMRs will improve care; however, little is known about the effect of EMR use on care quality in this setting. This study compares EMR versus paper medical record documentation of basic health history and preventive service indicators in 47 community-based practices. Differences in practice-level documentation rates between practices that did and did not use an EMR were examined using the Kruskal-Wallis nonparametric test and robust regression, adjusting for practice-level covariates. Frequency of documentation of health history and preventive service indicator items were similar in the 2 groups of practices. Although EMRs provide the capacity for more robust record keeping, the community-based practices here do not use EMRs to their full capacity. EMR usage does not guarantee more systematic record keeping and thus may not lead to improved quality in the community practice setting.
门诊环境中采用电子病历（EMR）已得到广泛推荐。人们希望电子病历能改善医疗服务；然而，对于在这种环境下使用电子病历对医疗质量的影响却知之甚少。本研究比较了47个社区医疗机构中电子病历与纸质病历在基本健康史和预防服务指标记录方面的情况。使用Kruskal-Wallis非参数检验和稳健回归分析，对使用和未使用电子病历的医疗机构在实践层面的记录率差异进行了检验，并对实践层面的协变量进行了调整。两组医疗机构在健康史和预防服务指标项目的记录频率上相似。尽管电子病历具备更强健的记录能力，但这里的社区医疗机构并未充分利用电子病历。使用电子病历并不能保证更系统的记录，因此在社区实践环境中可能不会带来质量的提升。
