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家庭医生是否在全面使用电子病历,以便这些数据可用于次要目的?加拿大的视角。

Are family physicians comprehensively using electronic medical records such that the data can be used for secondary purposes? A Canadian perspective.

作者信息

Tu Karen, Widdifield Jessica, Young Jacqueline, Oud William, Ivers Noah M, Butt Debra A, Leaver Chad A, Jaakkimainen Liisa

机构信息

Institute for Clinical Evaluative Sciences, G1 06, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.

Department of Family and Community Medicine, University of Toronto, Toronto, Canada.

出版信息

BMC Med Inform Decis Mak. 2015 Aug 13;15:67. doi: 10.1186/s12911-015-0195-x.


DOI:10.1186/s12911-015-0195-x
PMID:26268511
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC4535372/
Abstract

BACKGROUND: With the introduction and implementation of a variety of government programs and policies to encourage adoption of electronic medical records (EMRs), EMRs are being increasingly adopted in North America. We sought to evaluate the completeness of a variety of EMR fields to determine if family physicians were comprehensively using their EMRs and the suitability of use of the data for secondary purposes in Ontario, Canada. METHODS: We examined EMR data from a convenience sample of family physicians distributed throughout Ontario within the Electronic Medical Record Administrative data Linked Database (EMRALD) as extracted in the summer of 2012. We identified all physicians with at least one year of EMR use. Measures were developed and rates of physician documentation of clinical encounters, electronic prescriptions, laboratory tests, blood pressure and weight, referrals, consultation letters, and all fields in the cumulative patient profile were calculated as a function of physician and patient time since starting on the EMR. RESULTS: Of the 167 physicians with at least one year of EMR use, we identified 186,237 patients. Overall, the fields with the highest level of completeness were for visit documentations and prescriptions (>70%). Improvements were observed with increasing trends of completeness overtime for almost all EMR fields according to increasing physician time on EMR. Assessment of the influence of patient time on EMR demonstrated an increasing likelihood of the population of EMR fields overtime, with the largest improvements occurring between the first and second years. CONCLUSIONS: All of the data fields examined appear to be reasonably complete within the first year of adoption with the biggest increase occurring the first to second year. Using all of the basic functions of the EMR appears to be occurring in the current environment of EMR adoption in Ontario. Thus the data appears to be suitable for secondary use.

摘要

背景:随着各种政府计划和政策的出台与实施,以鼓励采用电子病历(EMR),北美地区对电子病历的采用率越来越高。我们试图评估各种电子病历字段的完整性,以确定家庭医生是否在全面使用他们的电子病历,以及这些数据在加拿大安大略省用于二级目的的适用性。 方法:我们检查了2012年夏季从电子病历管理数据链接数据库(EMRALD)中提取的、分布在安大略省各地的家庭医生便利样本的电子病历数据。我们确定了所有使用电子病历至少一年的医生。制定了相关测量方法,并计算了医生对临床诊疗、电子处方、实验室检查、血压和体重、转诊、会诊信以及累积患者档案中所有字段的记录率,这些记录率是医生和患者自开始使用电子病历以来时间的函数。 结果:在167名使用电子病历至少一年的医生中,我们识别出186,237名患者。总体而言,完整性最高的字段是诊疗记录和处方(>70%)。根据医生使用电子病历时间的增加,几乎所有电子病历字段的完整性都呈现出随时间增加的趋势。对患者使用电子病历时间影响的评估表明,随着时间推移,电子病历字段的填充可能性增加,最大的改进发生在第一年到第二年之间。 结论:所有检查的数据字段在采用的第一年内似乎都相当完整,最大的增长发生在第一年到第二年。在安大略省当前采用电子病历的环境中,似乎正在使用电子病历的所有基本功能。因此,这些数据似乎适合用于二级用途。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/da2b950d2da5/12911_2015_195_Fig5_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/70637b46b939/12911_2015_195_Fig1_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/98b3a48df4e4/12911_2015_195_Fig2_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/3c6cf73539cb/12911_2015_195_Fig3_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/08e636583dec/12911_2015_195_Fig4_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/da2b950d2da5/12911_2015_195_Fig5_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/70637b46b939/12911_2015_195_Fig1_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/98b3a48df4e4/12911_2015_195_Fig2_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/3c6cf73539cb/12911_2015_195_Fig3_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/08e636583dec/12911_2015_195_Fig4_HTML.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/ddb4/4535372/da2b950d2da5/12911_2015_195_Fig5_HTML.jpg

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本文引用的文献

[1]
Identifying individuals with multiple sclerosis in an electronic medical record.

Mult Scler. 2015-2

[2]
Evaluation of Electronic Medical Record Administrative data Linked Database (EMRALD).

Am J Manag Care. 2014

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