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MyPOD:一种基于电子病历的工具,有助于提高质量和维持认证。

MyPOD: an EMR-Based Tool that Facilitates Quality Improvement and Maintenance of Certification.

作者信息

Berman Loren, Duffy Brian, Randall Brenn B, Vinocur Charles

机构信息

Nemours-AI duPont Hospital for Children, Wilmington, DE, USA.

出版信息

J Med Syst. 2017 Mar;41(3):39. doi: 10.1007/s10916-017-0686-7. Epub 2017 Jan 19.

Abstract

Maintenance of Certification (MOC) was designed to assess physician competencies including operative case volume and outcomes. This information, if collected consistently and systematically, can be used to facilitate quality improvement. Information automatically extracted from the electronic medical record (EMR) can be used as a prompt to compile these data. We developed an EMR-based program called MyPOD (My Personal Outcomes Data) to track surgical outcomes at our institution. We compared occurrences reported in the first 18 months to those captured in the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) over the same time period. During the first 18 months of using MyPOD, 691 cases were captured in both MyPOD and NSQIP-P. There were 48 cases with occurrences in NSQIP-P (6.9% occurrence rate). MyPOD captured 33% of the occurrences and 83% of the deaths reported in NSQIP-P. Use of the MyPOD program helped to identify series of complications and facilitated systematic change to improve outcomes. MyPOD provides comparative data that is essential in performance evaluation and facilitates quality improvement in surgery. This program and similar EMR-driven tools are becoming essential components of the MOC process. Our initial review has revealed opportunities for improvement in self-reporting which we can continue to measure by comparison to NSQIP-P. In addition, it has identified systems issues that have led to hospital-wide improvements.

摘要

继续医学教育认证(MOC)旨在评估医生的能力,包括手术病例数量和治疗结果。如果能够持续且系统地收集这些信息,便可用于推动质量改进。从电子病历(EMR)中自动提取的信息可作为汇总这些数据的提示。我们开发了一个名为MyPOD(我的个人结果数据)的基于电子病历的程序,用于跟踪我们机构的手术结果。我们将前18个月报告的事件与同期美国外科医师学会国家外科质量改进计划 - 儿科版(ACS NSQIP - P)记录的事件进行了比较。在使用MyPOD的前18个月中,MyPOD和NSQIP - P均记录了691例病例。NSQIP - P中有48例发生了事件(发生率为6.9%)。MyPOD记录了NSQIP - P中报告的33%的事件和83%的死亡病例。使用MyPOD程序有助于识别一系列并发症,并促进系统性变革以改善治疗结果。MyPOD提供了在绩效评估中至关重要的比较数据,并有助于提高手术质量。该程序及类似的由电子病历驱动的工具正成为继续医学教育认证过程的重要组成部分。我们的初步审查发现了自我报告方面有待改进的地方,我们可以通过与NSQIP - P进行比较继续进行衡量。此外,它还识别出了导致全院改进的系统问题。

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