School of Social Work, University of North Carolina at Chapel Hill.
School of Social Work, University of Pittsburgh.
Fam Syst Health. 2021 Mar;39(1):77-88. doi: 10.1037/fsh0000584.
Integrated health care is utilized in primary care clinics to meet patients' physical, behavioral, and social needs. Current methods to collect and evaluate the effectiveness of integrated care require refinement. Using informatics and electronic health records (EHR) to distill large amounts of clinical data may help researchers measure the impact of integrated care more efficiently. This exploratory pilot study aimed to (a) determine the feasibility of using EHR documentation to identify behavioral health and social care components of integrated care, using social work as a use case, and (b) develop a lexicon to inform future research using natural language processing.
Study steps included development of a preliminary lexicon of behavioral health and social care interventions to address basic needs, creation of an abstraction guide, identification of appropriate EHR notes, manual chart abstraction, revision of the lexicon, and synthesis of findings.
Notes (N = 647) were analyzed from a random sample of 60 patients. Notes documented behavioral health and social care components of care but were difficult to identify due to inconsistencies in note location and titling. Although the interventions were not described in detail, the outcomes of screening, referral, and brief treatment were included. The integrated care team frequently used EHR to share information and communicate.
Opportunities and challenges to using EHR data were identified and need to be addressed to better understand the behavioral health and social care interventions in integrated care. To best leverage EHR data, future research must determine how to document and extract pertinent information about integrated team-based interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
综合医疗保健在初级保健诊所中得到应用，以满足患者的身体、行为和社会需求。目前收集和评估综合护理效果的方法需要改进。利用信息学和电子健康记录（EHR）来提炼大量临床数据，可能有助于研究人员更有效地衡量综合护理的效果。本探索性试点研究旨在：（a）确定使用 EHR 文档识别综合护理中的行为健康和社会护理部分的可行性，以社会工作为例；（b）开发一个词汇表，以便使用自然语言处理进行未来的研究。
研究步骤包括：开发一个解决基本需求的行为健康和社会关怀干预措施的初步词汇表、创建一个提取指南、确定适当的 EHR 记录、手动图表提取、词汇表修订以及综合研究结果。
从 60 名患者的随机样本中分析了 647 份记录。记录中记录了行为健康和社会护理部分的护理内容，但由于记录位置和标题不一致，难以识别。虽然干预措施没有详细描述，但包括了筛选、转介和简短治疗的结果。综合护理团队经常使用 EHR 来共享信息和进行沟通。
确定了使用 EHR 数据的机会和挑战，需要加以解决，以更好地了解综合护理中的行为健康和社会护理干预措施。为了更好地利用 EHR 数据，未来的研究必须确定如何记录和提取有关综合团队干预措施的相关信息。（PsycInfo 数据库记录（c）2021 APA，保留所有权利）。
