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电子病历中的心血管疾病记录与咨询

Cardiovascular disease documentation and counseling in electronic medical records.

作者信息

Bae Jaeyong, Huerta Timothy R, Ford Eric W

机构信息

School of Nursing and Health Studies, Northern Illinois University, Dekalb, IL, United States.

Departments of Family Medicine and Biomedical Informatics, The Ohio State University College of Medicine, Columbus Ohio, United States.

出版信息

Prev Med. 2016 Jul;88:27-32. doi: 10.1016/j.ypmed.2016.03.017. Epub 2016 Mar 23.

Abstract

The purpose of this paper is to explore the relationship between clinical reminders generated by electronic medical record (EMR) systems and providers giving prevention counseling to patients at-risk for cardiovascular disease (CVD). Data were extracted from the 2012 National Ambulatory Medical Care Survey (NAMCS). Results indicate that the providers routinely using clinical reminders are significantly more likely to document height and weight data to determine risk and provide the recommended counseling to patients that merit the intervention. The findings are important for policymakers and managers that have been promoting the adoption of more sophisticated EMR decision support functionalities across the care delivery spectrum. In particular, the ability to intervene prior to negative health events is an important feature of the movement to improve care quality and reduce costs.

摘要

本文旨在探讨电子病历(EMR)系统生成的临床提醒与为心血管疾病(CVD)高危患者提供预防咨询的医疗服务提供者之间的关系。数据取自2012年全国门诊医疗调查(NAMCS)。结果表明,经常使用临床提醒的医疗服务提供者更有可能记录身高和体重数据以确定风险,并向值得干预的患者提供推荐的咨询。这些发现对于一直在推动在整个医疗服务范围内采用更复杂的电子病历决策支持功能的政策制定者和管理人员来说很重要。特别是,在负面健康事件发生之前进行干预的能力是提高医疗质量和降低成本运动的一个重要特征。

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