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从 ADHD 患者的电子健康记录中提取数据,揭示了儿科医生对教育支持和文件收集的讨论。

Extracting Data from the Electronic Health Record of Patients with ADHD Reveals Pediatricians' Discussions of Educational Support and Document Collection.

机构信息

Division of Pediatric Psychology, Department of Pediatric and Adolescent Medicine.

Western Michigan University Homer Stryker M.D. School of Medicine.

出版信息

Perspect Health Inf Manag. 2023 Apr 1;20(2):1b. eCollection 2023 Spring.

Abstract

Primary care physicians (PCPs) have an important role in the identification and management of Attention Deficit Hyperactivity Disorder (ADHD). There is a paucity of research on PCPs' practices related to the discussion of educational interventions. We conducted a retrospective chart review using Natural Language Processing to extract data on how often PCPs in an outpatient clinic: 1) discuss educational support with patients and caregivers; and 2) obtain educational records. About three-quarters of patients had at least one term related to educational support included in at least one note, but only 13 percent of patients had at least one educational record uploaded into the electronic health record (EHR). There was no association between having an educational document uploaded into the EHR and inclusion of a term related to educational support in a note. Almost half (48 percent) of these records were unclearly labeled. Further education of PCPs is warranted to increase discussions of educational support and obtaining educational records, as is collaboration with health information management professionals around labeling.

摘要

初级保健医生(PCP)在识别和管理注意力缺陷多动障碍(ADHD)方面发挥着重要作用。关于 PCP 讨论教育干预措施的实践,相关研究甚少。我们使用自然语言处理进行了回顾性图表审查,以提取门诊诊所中 PCP 的以下数据:1)与患者和照顾者讨论教育支持;2)获取教育记录。大约四分之三的患者至少有一条与教育支持相关的术语包含在至少一条记录中,但只有 13%的患者至少有一份教育记录上传到电子健康记录(EHR)中。EHR 中是否上传教育文件与记录中包含与教育支持相关的术语之间没有关联。这些记录中有近一半(48%)的标签不明确。需要进一步对 PCP 进行教育,以增加对教育支持的讨论和获取教育记录,并与健康信息管理专业人员合作,共同解决标签问题。

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