信息技术提高了急诊科患者出院指导的完整性和国家质量指标的执行率：一项准实验研究。
Information technology improves Emergency Department patient discharge instructions completeness and performance on a national quality measure: a quasi-experimental study.
机构信息
Brigham and Women's Hospital , Boston, MA.
出版信息
Appl Clin Inform. 2013 Oct 23;4(4):499-514. doi: 10.4338/ACI-2013-07-RA-0046. eCollection 2013.
OBJECTIVE
To compare the completeness of Emergency Department (ED) discharge instructions before and after introduction of an electronic discharge instructions module by scoring compliance with the Centers for Medicare and Medicaid Services (CMS) Outpatient Measure 19 (OP-19).
METHODS
We performed a quasi-experimental study examining the impact of an electronic discharge instructions module in an academic ED. Three hundred patients discharged home from the ED were randomly selected from two time intervals: 150 patients three months before and 150 patients three to five months after implementation of the new electronic module. The discharge instructions for each patient were reviewed, and compliance for each individual OP-19 element as well as overall OP-19 compliance was scored per CMS specifications. Compliance rates as well as risk ratios (RR) and risk differences (RD) with 95% confidence intervals (CI) comparing the overall OP-19 scores and individual OP-19 element scores of the electronic and paper-based discharge instructions were calculated.
RESULTS
The electronic discharge instructions had 97.3% (146/150) overall OP-19 compliance, while the paper-based discharge instructions had overall compliance of 46.7% (70/150). Electronic discharge instructions were twice as likely to achieve overall OP-19 compliance compared to the paper-based format (RR: 2.09, 95% CI: 1.75 - 2.48). The largest improvement was in documentation of major procedures and tests performed: only 60% of the paper-based discharge instructions satisfied this criterion, compared to 100% of the electronic discharge instructions (RD: 40.0%, 95% CI: 32.2% - 47.8%). There was a modest difference in medication documentation with 92.7% for paper-based and 100% for electronic formats (RD: 7.3%, 95% CI: 3.2% - 11.5%). There were no statistically significant differences in documentation of patient care instructions and diagnosis between paper-based and electronic formats.
CONCLUSION
With careful design, information technology can improve the completeness of ED patient discharge instructions and performance on the OP-19 quality measure.
目的
通过对符合医疗保险和医疗补助服务中心（CMS）门诊措施 19 号（OP-19）的标准的评分，比较电子出院指导模块引入前后急诊（ED）出院指导的完整性。
方法
我们进行了一项准实验研究，考察了学术 ED 中电子出院指导模块的影响。从两个时间段中随机选择了 300 名从 ED 出院回家的患者：150 名患者在新电子模块实施前三个月，150 名患者在实施后三到五个月。回顾每位患者的出院指导，根据 CMS 规范对每个单独的 OP-19 元素以及整体 OP-19 合规性进行评分。计算整体 OP-19 评分以及电子和基于纸张的出院指导的各个 OP-19 元素评分的符合率以及风险比（RR）和风险差异（RD），并计算其 95％置信区间（CI）。
结果
电子出院指导的整体 OP-19 符合率为 97.3％（146/150），而基于纸张的出院指导的整体符合率为 46.7％（70/150）。与基于纸张的格式相比，电子出院指导实现整体 OP-19 符合率的可能性是其两倍（RR：2.09，95％CI：1.75-2.48）。最大的改进是记录主要程序和已执行的检查：只有 60％的基于纸张的出院指导符合此标准，而电子出院指导则为 100％（RD：40.0％，95％CI：32.2％-47.8％）。药物记录方面存在适度差异，基于纸张的格式为 92.7％，而电子格式为 100％（RD：7.3％，95％CI：3.2％-11.5％）。在患者护理指导和诊断的记录方面，基于纸张和电子格式之间没有统计学上的显着差异。
结论
通过精心设计，信息技术可以提高 ED 患者出院指导的完整性，并提高 OP-19 质量措施的绩效。
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