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结肠和直肠手术的临床决策支持:综述

Clinical decision support for colon and rectal surgery: an overview.

作者信息

McCoy Allison B, Melton Genevieve B, Wright Adam, Sittig Dean F

机构信息

School of Biomedical Informatics, The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas ; UT-Memorial Hermann Center for Healthcare Quality and Safety, Houston, Texas.

Institute for Health Informatics, University of Minnesota, Minneapolis, Minnesota ; Department of Surgery, University of Minnesota, Minneapolis, Minnesota.

出版信息

Clin Colon Rectal Surg. 2013 Mar;26(1):23-30. doi: 10.1055/s-0033-1333644.

Abstract

Clinical decision support (CDS) has been shown to improve clinical processes, promote patient safety, and reduce costs in healthcare settings, and it is now a requirement for clinicians as part of the Meaningful Use Regulation. However, most evidence for CDS has been evaluated primarily in internal medicine care settings, and colon and rectal surgery (CRS) has unique needs with CDS that are not frequently described in the literature. The authors reviewed published literature in informatics and medical journals, combined with expert opinion to define CDS, describe the evidence for CDS, outline the implementation process for CDS, and present applications of CDS in CRS.CDS functionalities such as order sets, documentation templates, and order facilitation aids are most often described in the literature and most likely to be beneficial in CRS. Further research is necessary to identify and better evaluate additional CDS systems in the setting of CRS.

摘要

临床决策支持(CDS)已被证明可改善临床流程、促进患者安全并降低医疗保健环境中的成本,并且作为《有意义使用条例》的一部分,它现在是临床医生的一项要求。然而,大多数关于CDS的证据主要是在内科护理环境中评估的,而结肠直肠手术(CRS)在CDS方面有独特需求,这些需求在文献中并不常被描述。作者回顾了信息学和医学期刊上发表的文献,并结合专家意见来定义CDS、描述CDS的证据、概述CDS的实施过程,并介绍CDS在CRS中的应用。诸如医嘱集、文档模板和医嘱辅助工具等CDS功能在文献中最常被描述,并且在CRS中最有可能有益。有必要进行进一步研究,以识别并更好地评估CRS环境中的其他CDS系统。

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