Safran C, Porter D, Lightfoot J, Rury C D, Underhill L H, Bleich H L, Slack W V
Beth Israel Hospital, Boston, Massachusetts.
Ann Intern Med. 1989 Nov 1;111(9):751-6. doi: 10.7326/0003-4819-111-9-751.
We designed a user-friendly computer program that permits physicians to search the clinical database of Boston's Beth Israel Hospital by clinical and demographic descriptors. For example, the user can identify all admissions in which diabetic ketoacidosis was diagnosed, the serum bicarbonate level was under 12 mmol/L, and the length of stay exceeded 7 days. Once particular admissions are identified, all data stored in the computerized record can be displayed. Authorized persons can also request the patient's complete medical record for further study. Over a 30-month period, 530 doctors, nurses, medical students, and administrators used the program to search the hospital's clinical database 1786 times. They displayed detailed information on 30,851 patients and requested the complete medical record 5319 times. In 1389 of the 1786 searches completed, the searcher responded to a computer-based questionnaire about motivation for the search. Responses indicated that 32% of the searches were for clinical research, 17% for patient care, 17% for teaching and education, 11% for hospital administration, and 12% for general exploration. In 58% of the searches, respondents indicated definite or probable success in finding the desired information. We conclude that physicians and allied personnel will repeatedly obtain, view, and analyze aggregate clinical information if they are provided with appropriate tools. We believe that such access to clinical information is an important resource for patient care, teaching, and clinical research.
我们设计了一个用户友好的计算机程序，该程序允许医生通过临床和人口统计学描述符搜索波士顿贝斯以色列医院的临床数据库。例如，用户可以识别所有诊断为糖尿病酮症酸中毒、血清碳酸氢盐水平低于12 mmol/L且住院时间超过7天的入院病例。一旦确定了特定的入院病例，计算机记录中存储的所有数据都可以显示出来。授权人员还可以要求获取患者的完整病历以供进一步研究。在30个月的时间里，530名医生、护士、医学生和管理人员使用该程序搜索医院的临床数据库1786次。他们显示了30851名患者的详细信息，并5319次要求获取完整病历。在完成的1786次搜索中，有1389次搜索者回复了一份关于搜索动机的基于计算机的问卷。回复表明，32%的搜索是用于临床研究，17%用于患者护理，17%用于教学和教育，11%用于医院管理，12%用于一般探索。在58%的搜索中，受访者表示在找到所需信息方面有一定或可能的成功。我们得出结论，如果为医生和相关人员提供适当的工具，他们将反复获取、查看和分析汇总的临床信息。我们认为，这种获取临床信息的方式是患者护理、教学和临床研究的重要资源。
