Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, USA.
Center for Clinical Informatics and Improvement Research, Department of Medicine, University of California, San Francisco, San Francisco, California, USA.
J Am Med Inform Assoc. 2022 Dec 13;30(1):8-15. doi: 10.1093/jamia/ocac201.
To determine whether novel measures of contextual factors from multi-site electronic health record (EHR) audit log data can explain variation in clinical process outcomes.
We selected one widely-used process outcome: emergency department (ED)-based team time to deliver tissue plasminogen activator (tPA) to patients with acute ischemic stroke (AIS). We evaluated Epic audit log data (that tracks EHR user-interactions) for 3052 AIS patients aged 18+ who received tPA after presenting to an ED at three Northern California health systems (Stanford Health Care, UCSF Health, and Kaiser Permanente Northern California). Our primary outcome was door-to-needle time (DNT) and we assessed bivariate and multivariate relationships with six audit log-derived measures of treatment team busyness and prior team experience.
Prior team experience was consistently associated with shorter DNT; teams with greater prior experience specifically on AIS cases had shorter DNT (minutes) across all sites: (Site 1: -94.73, 95% CI: -129.53 to 59.92; Site 2: -80.93, 95% CI: -130.43 to 31.43; Site 3: -42.95, 95% CI: -62.73 to 23.17). Teams with greater prior experience across all types of cases also had shorter DNT at two sites: (Site 1: -6.96, 95% CI: -14.56 to 0.65; Site 2: -19.16, 95% CI: -36.15 to 2.16; Site 3: -11.07, 95% CI: -17.39 to 4.74). Team busyness was not consistently associated with DNT across study sites.
EHR audit log data offers a novel, scalable approach to measure key contextual factors relevant to clinical process outcomes across multiple sites. Audit log-based measures of team experience were associated with better process outcomes for AIS care, suggesting opportunities to study underlying mechanisms and improve care through deliberate training, team-building, and scheduling to maximize team experience.
确定来自多站点电子健康记录（EHR）审核日志数据的新的上下文因素测量方法是否可以解释临床流程结果的变化。
我们选择了一种广泛使用的流程结果：在急诊科（ED）中向急性缺血性中风（AIS）患者提供组织型纤溶酶原激活剂（tPA）的团队时间。我们评估了来自加利福尼亚北部三个健康系统（斯坦福健康医疗中心，加州大学旧金山分校健康中心和 Kaiser Permanente Northern California）的 3052 名接受 ED 治疗的 18 岁及以上 AIS 患者的 Epic 审核日志数据（该数据跟踪 EHR 用户交互）。我们的主要结果是门到针时间（DNT），并评估了与治疗团队繁忙程度和先前团队经验相关的六个审核日志衍生测量值的双变量和多变量关系。
先前的团队经验与更短的 DNT 始终相关；在所有站点中，具有更多先前 AIS 经验的团队具有更短的 DNT（分钟）：（站点 1：-94.73，95％CI：-129.53 至 59.92；站点 2：-80.93，95％CI：-130.43 至 31.43；站点 3：-42.95，95％CI：-62.73 至 23.17）。在两个站点中，具有更多所有类型病例经验的团队也具有更短的 DNT：（站点 1：-6.96，95％CI：-14.56 至 0.65；站点 2：-19.16，95％CI：-36.15 至 2.16；站点 3：-11.07，95％CI：-17.39 至 4.74）。团队繁忙程度在整个研究站点与 DNT 之间并不始终相关。
EHR 审核日志数据提供了一种新颖的，可扩展的方法来衡量与多个站点的临床流程结果相关的关键上下文因素。基于审核日志的团队经验测量方法与 AIS 护理的更好流程结果相关，这表明有机会通过精心设计的培训，团队建设和排班来研究潜在机制并改善护理，以最大程度地提高团队经验。
