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电子提醒对基层医疗中诊断记录的影响:一项前后对照的准实验研究。

The effect of electronic reminders on the recording of diagnoses in primary care: A quasi-experimental before and after study.

作者信息

Lehtovuori Tuomo, Heikkinen Anna M, Raina Marko, Kauppila Timo

机构信息

The Health Center of Leppävaara, City of Espoo, Espoo, Finland.

Department of Oral and Maxillofacial Diseases, Head and Neck Center, University of Helsinki, Helsinki, Finland.

出版信息

SAGE Open Med. 2020 Apr 28;8:2050312120918267. doi: 10.1177/2050312120918267. eCollection 2020.

Abstract

This study examined whether using electronic reminders leads to an increase in the rate of diagnosis recordings in the electronic health record system following visits to a general practitioner. The impact of electronic reminders was studied in the primary health care of a Finnish city. This observational quasi-experimental study based on a before-and-after design was carried out by installing an electronic reminder to improve the recording of diagnoses in the computerized electronic health record system. The quantity of the recorded diagnoses was observed before and after the intervention. The effect of this intervention on the distribution of different diagnoses was also studied. Before intervention, 33%-46% of visits (to general practitioners/month) had recorded diagnose in the primary health care units. After 4 years, the recording rate had risen to 87%-95% (p < 0.001). The rate of change in the recording of diagnoses was highest during the first year of intervention and plateaued about 3.5 years after application reminders. In the present study, most of the visits concerned mild respiratory infections, elevated blood pressure, low back pain and type 2 diabetes. An electronic reminder is likely to improve the recording of diagnoses during the visits to general practitioners. The distribution of diagnoses was in line with former reports concerning diagnoses in Finnish primary care.

摘要

本研究调查了使用电子提醒是否会导致在全科医生就诊后电子健康记录系统中的诊断记录率上升。在芬兰一个城市的初级卫生保健中研究了电子提醒的影响。这项基于前后设计的观察性准实验研究,通过安装电子提醒来改进计算机化电子健康记录系统中诊断的记录。在干预前后观察记录的诊断数量。还研究了这种干预对不同诊断分布的影响。干预前,在初级卫生保健单位中,33%-46%的就诊(每月到全科医生处)有诊断记录。4年后,记录率上升到87%-95%(p<0.001)。诊断记录的变化率在干预的第一年最高,并在应用提醒约3.5年后趋于平稳。在本研究中,大多数就诊涉及轻度呼吸道感染、高血压、腰痛和2型糖尿病。电子提醒可能会改善在全科医生就诊期间诊断的记录。诊断分布与之前关于芬兰初级保健中诊断的报告一致。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/5cc3/7222644/c4855bb17d9f/10.1177_2050312120918267-fig1.jpg

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