Austin Robin R, Monsen Karen A, Schulz Craig
University of Minnesota School of Nursing.
University of Minnesota, School of Nursing.
J Innov Health Inform. 2017 Oct 6;24(3):929. doi: 10.14236/jhi.v24i3.929.
Low back pain (LBP) is a complex health care issue that often involves multiple providers across various care settings. Health information technology (HIT) holds promise to improve care delivery by providing infrastructure for communication, clinical documentation, and management of patient data. Standardized terminology is essential for interoperability and enables evaluation of clinical data generated by documentation in an electronic health record (EHR).
The purpose of this study was to demonstrate the feasibility of mapping evidence-based practice for conservative management of low back pain to the Omaha System and foster inter-professional communication and collaboration among diverse practitioners and patients.
Evidence-based practice (EBP) guidelines for non-invasive treatment of low back pain were mapped to the Omaha System using a clinical expert approach with attention to content feasibility, linguistic validity, and granularity of terms.
A clinical guideline for low back pain management was developed consisting of 13 interventions for Pain and Neuro-musculo-skeletal problems. The most common intervention categories were Case management followed by Treatments and procedures, Teaching, guidance, and counseling and Surveillance. Scope of practice overlap was identified between primary care, chiropractic, and physical therapy practice.
Use of the guideline may facilitate clinical documentation using the Omaha System for low back pain management, and has potential to generate meaningful data to evaluate clinical effectiveness and promote quality research. The use of encoded EBP evidence within an EHR can increase use of available evidence, enable interprofessional communication, improve quality of care, and enhance usability of data across care settings.
腰痛是一个复杂的医疗保健问题,通常涉及不同护理环境中的多个提供者。健康信息技术(HIT)有望通过提供通信基础设施、临床文档和患者数据管理来改善护理服务。标准化术语对于互操作性至关重要,并能够评估电子健康记录(EHR)中由文档生成的临床数据。
本研究的目的是证明将基于证据的腰痛保守管理实践映射到奥马哈系统的可行性,并促进不同从业者和患者之间的跨专业沟通与协作。
采用临床专家方法,将基于证据的腰痛非侵入性治疗实践指南映射到奥马哈系统,同时关注内容可行性、语言有效性和术语粒度。
制定了一项腰痛管理临床指南,包括针对疼痛和神经肌肉骨骼问题的13项干预措施。最常见的干预类别是病例管理,其次是治疗和程序、教学、指导和咨询以及监测。确定了初级保健、脊椎按摩疗法和物理治疗实践之间的实践范围重叠。
使用该指南可能有助于使用奥马哈系统进行腰痛管理的临床文档记录,并有可能生成有意义的数据来评估临床效果并促进高质量研究。在电子健康记录中使用编码的循证医学证据可以增加可用证据的使用,实现跨专业沟通,提高护理质量,并增强不同护理环境中数据的可用性。