Professor of Primary Care Research & Development, eHealth Research Group, Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9AG, UK.
BMJ Qual Saf. 2012 Apr;21(4):337-46. doi: 10.1136/bmjqs-2011-000450. Epub 2012 Feb 10.
Patient histories in electronic health records currently exist mainly in free text format thereby limiting the possibility that decision support technology may contribute to the accuracy and timeliness of clinical diagnoses. Structuring and/or coding make patient histories potentially computable.
A systematic review was undertaken of the benefits and risks of structuring and/or coding patient history by searching nine international databases for published and unpublished studies over the period 1990-2010. The focus was on the current patient history, defined as information reported by a patient or the patient's caregiver about the patient's present health situation and health status. Findings were synthesised through a theoretically based textural analysis.
Of the 9207 potentially eligible papers identified, 10 studies satisfied the eligibility criteria. There was evidence of a modest number of benefits associated with structuring the current patient history, including obtaining more complete clinical histories, improved accuracy of patient self-documented histories, and better associated decision-making by professionals. However, no studies demonstrated any resulting improvements in patient care or outcomes. When more detailed records were obtained through the use of a structured format no attempt was made to confirm if this additional information was clinically useful. No studies investigated possible risks associated with structuring the patient history. No studies examined coding of the patient history.
There is an insufficient evidence base for sound policy making on the benefits and risks of structuring and/or coding patient history. The authors suggest this field of enquiry warrants further investigation given the interest in use of decision support technology to aid diagnoses.
电子健康记录中的患者病史目前主要以自由文本格式存在，从而限制了决策支持技术可能有助于提高临床诊断准确性和及时性的可能性。结构化和/或编码使患者病史具有潜在的可计算性。
通过搜索 1990 年至 2010 年期间的九个国际数据库，对结构化和/或编码患者病史的益处和风险进行了系统评价，搜索范围包括已发表和未发表的研究。重点是当前的患者病史，定义为患者或患者的照顾者报告的关于患者当前健康状况和健康状况的信息。通过基于理论的文本分析对研究结果进行了综合。
在 9207 篇潜在合格的论文中，有 10 篇符合入选标准。有证据表明，结构化当前患者病史具有一定的益处，包括获得更完整的临床病史、提高患者自我记录病史的准确性以及专业人员更好地做出相关决策。然而，没有研究表明患者护理或结果有任何改善。当通过使用结构化格式获得更详细的记录时，并没有试图确认这些额外信息在临床上是否有用。没有研究调查与结构化患者病史相关的任何潜在风险。没有研究检查患者病史的编码。
关于结构化和/或编码患者病史的益处和风险，目前的证据基础不足，无法为制定合理的政策提供依据。鉴于人们对使用决策支持技术辅助诊断的兴趣，作者建议进一步调查这一研究领域。
