计算机化医嘱录入与临床决策支持系统的使用可减少术前检查医嘱的实践差异：一项回顾性队列研究。
The use of computerized physician order entry with clinical decision support reduces practice variance in ordering preoperative investigations: A retrospective cohort study.
机构信息
Department of Anaesthesiology, Singapore General Hospital,Outram Road, Singapore 169608, Singapore.
Duke-NUS Medical School, 8 College Road, Singapore 169857, Singapore.
出版信息
Int J Med Inform. 2017 Dec;108:29-35. doi: 10.1016/j.ijmedinf.2017.09.015. Epub 2017 Sep 28.
BACKGROUND AND GOAL OF STUDY
Over-ordering of routine preoperative investigations is prevalent. Adherence to institutional guidelines differs among physicians. Our institution integrated a Clinical Decision Support (CDS) model into our hospital's Computerized Physician Ordering Entry (CPOE) system to guide physician orders. We investigate if the implementation of CDS into CPOE increases physician adherence to our institutional guidelines.
METHODS
A retrospective cohort study in a tertiary academic hospital over 18 months. The CDS model incorporated into the hospital's CPOE system prompts preoperative investigations based on the patient's age, gender, American Society of Anesthesiologists (ASA) score and complexity of the surgery when physicians use the Electronic Admission Form (EAF). These investigations include: Full Blood Count (FBC), Chest Radiography (CXR), Coagulation Panel (CP), Renal Panel (RP) and Electrocardiogram (ECG). Orders are 'concordant' if they followed guidelines; 'over' if they were not required by guidelines, and 'under' if they were required by guidelines but not ordered.
RESULTS AND DISCUSSION
11,792 patients - 7977 patients in the pre-implementation group, and 3815 patients in the post-implementation group. After implementation of CDS, overall guideline-concordant ordering rate increased by 3.9%, over orders decreased by 0.6% and under-orders decreased by 3.3% (P<0.001). CP showed the greatest increase in concordant orders by 12.0% and greatest decrease in under-orders by 11.1%. RP, ECG and CXR also showed modest increases in concordance rate. No significant change in ordering of FBC was found, due to the high pre-implementation concordance frequency of 96.3%. ECG and CXR have the lowest rates of concordant orders and highest rates of 'over' orders in both groups. Concordant orders were lowest in ASA 1 patients, and better in patients with higher ASA. Concordant orders across all ASA scores improved significantly after CDS was implemented.
CONCLUSION
Implementation of CDS model into the CPOE system has improved physician adherence to guidelines for certain preoperative investigations.
背景与研究目的
常规术前检查过度开单较为普遍，不同医生对机构指南的遵循程度存在差异。我们的机构将临床决策支持（CDS）模型整合到医院的计算机化医嘱录入系统（CPOE）中，以指导医生下医嘱。我们调查了将 CDS 整合到 CPOE 中是否会增加医生对机构指南的遵循程度。
方法
在一家三级学术医院进行了 18 个月的回顾性队列研究。当医生使用电子入院表（EAF）时，CDS 模型会根据患者的年龄、性别、美国麻醉医师协会（ASA）评分和手术的复杂性，提示进行术前检查。这些检查包括：全血细胞计数（FBC）、胸部 X 光片（CXR）、凝血酶原时间（CP）、肾功能检查（RP）和心电图（ECG）。如果医嘱符合指南要求，则为“一致”；如果不符合指南要求，则为“过度”；如果指南要求但未下医嘱，则为“不足”。
结果与讨论
共纳入 11792 例患者，其中实施前组 7977 例，实施后组 3815 例。实施 CDS 后，总体符合指南的医嘱开具率提高了 3.9%，过度医嘱减少了 0.6%，不足医嘱减少了 3.3%（P<0.001）。CP 的一致医嘱开具率增加了 12.0%，不足医嘱减少了 11.1%，这两项改变最大。RP、ECG 和 CXR 的一致性也有适度提高。由于实施前 FBC 的一致性频率高达 96.3%，因此 FBC 的医嘱开具没有明显变化。ECG 和 CXR 在两组中均具有最低的一致医嘱开具率和最高的“过度”医嘱开具率。ASA 1 患者的一致医嘱开具率最低，ASA 较高的患者则更好。实施 CDS 后，所有 ASA 评分的一致医嘱开具率均显著提高。
结论
将 CDS 模型整合到 CPOE 系统中，可以提高医生对某些术前检查的指南遵循程度。
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