Garrison Gregory M, Traverse Chelsea R, Fish Robert G
Department of Family Medicine, Mayo Clinic, Rochester, MN, USA.
Health Serv Res Manag Epidemiol. 2016 Jun 16;3:2333392816650344. doi: 10.1177/2333392816650344. eCollection 2016 Jan-Dec.
In the traditional model of care, an annual visit was dedicated to the task of assessing and delivering preventive care. With the move away from annual physicals, primary care physicians are addressing preventive services at every clinic visit often aided by electronic clinical decision support (CDS) systems.
We conducted a case study of a visit-driven CDS system in use at a primary care clinic. Steady-state performance was assessed via control charts of quality metrics, data regarding completion of recommendations, and an analysis of screening intervals achieved with patient visits.
Under this visit-driven CDS system, quality metric performance was poor and declining. Almost half of the patients were not screened (46.5%), and the other half were overscreened the majority of the time (83.3%). Recommended preventive services were ordered less than half the time (42.6%), despite CDS reminders.
Various barriers and systematic inefficiencies combined to produce ineffective screening in this visit-driven CDS preventive service delivery system. As a result, we conclude a visit-driven system cannot produce optimal results. In order to improve performance, preventive services should be delivered separately from clinical visits, perhaps by a "preventive service ranger" (PSR) utilizing the CDS system to review each patient once annually. Under such a system, patients would receive preventive services in an organized and efficient fashion, potentially leading to better continuity, higher quality metrics that are mathematically predictable, and improved satisfaction.
在传统医疗模式中，年度就诊专门用于评估和提供预防性医疗服务。随着不再进行年度体检，初级保健医生在每次诊所就诊时都在处理预防性服务，这通常借助电子临床决策支持（CDS）系统。
我们对一家初级保健诊所使用的基于就诊的CDS系统进行了案例研究。通过质量指标控制图、关于建议完成情况的数据以及对患者就诊时实现的筛查间隔的分析来评估稳态性能。
在这个基于就诊的CDS系统下，质量指标表现不佳且呈下降趋势。几乎一半的患者未接受筛查（46.5%），另一半在大多数情况下接受了过度筛查（83.3%）。尽管有CDS提醒，但推荐的预防性服务被开具的时间不到一半（42.6%）。
在这个基于就诊的CDS预防性服务提供系统中，各种障碍和系统低效共同导致了无效的筛查。因此，我们得出结论，基于就诊的系统无法产生最佳结果。为了提高性能，预防性服务应与临床就诊分开提供，或许可以由一名“预防性服务专员”（PSR）利用CDS系统每年对每位患者进行一次评估。在这样的系统下，患者将以有组织、高效的方式接受预防性服务，这可能会带来更好的连续性、数学上可预测的更高质量指标以及更高的满意度。
