Claire Simon Kelly, Hentati Afif, Rubin Susan, Franada Tiffani, Maurer Darryck, Hillman Laura, Tideman Samuel, Szela Monika, Meyers Steven, Frigerio Roberta, Maraganore Demetrius M
Department of Neurology, NorthShore University HealthSystem, USA.
Health Information Technology, NorthShore University HealthSystem, USA.
Mult Scler J Exp Transl Clin. 2018 Nov 30;4(4):2055217318813736. doi: 10.1177/2055217318813736. eCollection 2018 Oct-Dec.
Many physicians enter data into the electronic medical record (EMR) as unstructured free text and not as discrete data, making it challenging to use for quality improvement or research initiatives.
The objective of this research paper was to develop and implement a structured clinical documentation support (SCDS) toolkit within the EMR to facilitate quality initiatives and practice-based research in a multiple sclerosis (MS) practice.
We built customized EMR toolkits to capture standardized data at office visits. Content was determined through physician consensus on necessary elements to support best practices in treating patients with demyelinating disorders. We also developed CDS tools and best practice advisories within the toolkits to alert physicians when a quality improvement opportunity exists, including enrollment into our DNA biobanking study at the point of care.
We have used the toolkit to evaluate 541 MS patients in our clinic and begun collecting longitudinal data on patients who return for annual visits. We provide a description and example screenshots of our toolkits, and a brief description of our cohort to date.
The EMR can be effectively structured to standardize MS clinic office visits, capture data, and support quality improvement and practice-based research initiatives at the point of care.
许多医生将数据以非结构化的自由文本形式录入电子病历（EMR），而非离散数据，这使得其难以用于质量改进或研究项目。
本研究论文的目的是在电子病历中开发并实施结构化临床文档支持（SCDS）工具包，以促进多发性硬化症（MS）诊疗实践中的质量改进举措和基于实践的研究。
我们构建了定制的电子病历工具包，以在门诊就诊时获取标准化数据。内容是通过医生就支持脱髓鞘疾病患者最佳治疗实践的必要要素达成共识而确定的。我们还在工具包中开发了临床决策支持（CDS）工具和最佳实践建议，以便在存在质量改进机会时提醒医生，包括在医疗点登记参加我们的DNA生物样本库研究。
我们已使用该工具包对诊所中的541名MS患者进行了评估，并开始收集每年复诊患者的纵向数据。我们提供了工具包的描述和示例屏幕截图，以及对我们目前队列的简要描述。
电子病历可以有效地结构化，以规范MS诊所的门诊就诊、获取数据，并在医疗点支持质量改进和基于实践的研究项目。
