Deparment of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
J Am Med Inform Assoc. 2013 Jun;20(e1):e97-e101. doi: 10.1136/amiajnl-2012-001308. Epub 2013 Jan 23.
To develop an electronic registry of patients with chronic kidney disease (CKD) treated in a nephrology practice in order to provide clinically meaningful measurement and population management to improve rates of blood pressure (BP) control.
We combined data from multiple electronic sources: the billing system, structured fields in the electronic health record (EHR), and free text physician notes using natural language processing (NLP). We also used point-of-care worksheets to capture clinical rationale.
Nephrologist billing accurately identified patients with CKD. Using an algorithm that incorporated multiple BP readings increased the measured rate of control (130/80 mm Hg) from 37.1% to 42.3%. With the addition of NLP to capture BP readings from free text notes, the rate was 52.6%. Data from point-of-care worksheets indicated that in 52% of visits in which patients were identified as not having controlled BP, patients were actually at goal based on BP readings taken at home or on that day in the office.
Building a method for clinically meaningful continuous performance measurement of BP control is possible, but will require data from multiple sources. Electronic measurement systems need to grow to be able to capture and process performance data from patients as well as in real-time from physicians.
开发一个用于肾病学实践中治疗慢性肾脏病 (CKD) 患者的电子注册系统,以便提供有临床意义的测量和人群管理,以提高血压 (BP) 控制率。
我们结合了多个电子源的数据:计费系统、电子病历 (EHR) 中的结构化字段和使用自然语言处理 (NLP) 的自由文本医师笔记。我们还使用即时工作表来记录临床原理。
肾病学家的计费准确地识别出患有 CKD 的患者。使用一种算法,该算法合并了多个 BP 读数,将控制率的测量值(130/80 mmHg)从 37.1%提高到 42.3%。通过添加 NLP 来从自由文本笔记中捕获 BP 读数,该比率为 52.6%。即时工作表的数据表明,在 52%的就诊中,患者被认为没有控制 BP,但实际上根据在家中或当天在办公室测量的 BP 读数,患者已经达到目标。
建立一种用于 BP 控制的有临床意义的持续绩效测量方法是可行的,但需要来自多个来源的数据。电子测量系统需要发展,以便能够捕获和处理来自患者以及实时来自医生的绩效数据。