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一种基于电子健康记录的方法,用于构建、规范和自动化药剂师的临床文档任务,以生成可提取的结果。

An EHR-based method to structure, standardize, and automate clinical documentation tasks for pharmacists to generate extractable outcomes.

作者信息

Sanders Kimberly A, Wolverton Daniel, Stamopoulos Marina, Zunich Rada, Niznik Joshua, Ferreri Stefanie P

机构信息

Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA.

Department of Pharmacy, UNC Health, Chapel Hill, North Carolina, USA.

出版信息

JAMIA Open. 2023 May 11;6(2):ooad034. doi: 10.1093/jamiaopen/ooad034. eCollection 2023 Jul.

Abstract

As the recognition of team-based care grows and pharmacists increase in patient care interventions, it is important that tools to track clinical services are easily accessible and well-integrated into workflow for all providers. We describe and discuss feasibility and implementation of data tools in an electronic health record to evaluate a pragmatic clinical pharmacy intervention focused on deprescribing in aged adults delivered at multiple clinical sites in a large academic health system. Of the data tools utilized, we were able to demonstrate clear documentation frequency of certain phrases during the intervention period for 574 patients receiving opioids and 537 patients receiving benzodiazepines. Although clinical decision support and documentation tools exist, they are underutilized or cumbersome to integrate into primary health care and strategies, such as employed, are a solution. This communication incorporates the importance of clinical pharmacy information systems in research design.

摘要

随着对团队式护理的认识不断提高,药剂师在患者护理干预方面的作用日益增强,对于所有医疗服务提供者而言,能够轻松获取并很好地融入工作流程的临床服务跟踪工具至关重要。我们描述并讨论了电子健康记录中数据工具的可行性和实施情况,以评估一项针对大型学术健康系统中多个临床地点老年患者减药的务实临床药学干预措施。在所使用的数据工具中,我们能够证明在干预期间,574名接受阿片类药物治疗的患者和537名接受苯二氮䓬类药物治疗的患者某些短语的明确记录频率。尽管存在临床决策支持和记录工具,但它们未得到充分利用,或者难以集成到初级卫生保健中,而采用的策略就是一种解决方案。本交流阐述了临床药学信息系统在研究设计中的重要性。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/9d7f/10174697/1acf4b6287a9/ooad034f1.jpg

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