Department of Pediatrics, University of Rochester School of Medicine & Dentistry, Rochester, New York, USA.
J Am Med Inform Assoc. 2014 Feb;21(e1):e152-6. doi: 10.1136/amiajnl-2013-002260. Epub 2013 Sep 6.
The objective was to assess whether rates of preventive counseling delivered at well child visits (WCVs) differ for practices with basic, fully functional, or no electronic health record (EHR). Cross-sectional analyses of WCVs included in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Electronic Medical Records Supplement, 2007-2010 were performed. Practices with fully functional EHRs documented delivery of 34% more counseling topics than those without an EHR. WCVs with a fully functional EHR lasted 3.5 more minutes than those with a basic EHR. Overall, for each additional 10 min, 12% more topics were covered, regardless of EHR functionality. Further studies should assess the impact of such systems on the quality of patient care during preventive care visits and on health outcomes.
目的在于评估在提供儿童常规健康检查（WCVs）时，具有基本功能、完全功能和无电子健康记录（EHR）的实践之间的预防咨询率是否存在差异。对 2007-2010 年全国门诊医疗调查和全国医院门诊医疗调查电子病历补充调查中包含的 WCV 进行了横断面分析。具有完全功能的 EHR 的实践记录了 34%更多的咨询主题，而没有 EHR 的实践则没有。具有完全功能 EHR 的 WCV 比具有基本 EHR 的 WCV 长 3.5 分钟。总的来说，无论 EHR 的功能如何，每增加 10 分钟，就会多涵盖 12%的主题。进一步的研究应该评估这些系统对预防保健就诊期间患者护理质量和健康结果的影响。
