Lindholm Tanja, Lias Noora, Kvarnström Kirsi, Holmström Anna-Riia, Toivo Terhi, Uusitalo Marjo, Nurmi Harri, Airaksinen Marja
Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.
HUS Pharmacy, Helsinki University Hospital, Helsinki, Finland.
J Med Internet Res. 2025 May 6;27:e70133. doi: 10.2196/70133.
Poor data transfer and interoperability between electronic health record (EHR) systems has been a challenge hindering availability and usability of patient information in clinical practice and evidence-based decision-making. To improve data transfer and interoperability, patient information should be documented in a structured format. This also applies to medication-related patient information and results of the interventions, such as medication reviews (MRs), to individually optimize medication regimens, especially in older adults.
This study aimed to identify what information obtained from MRs should be documented in a structured form in EHRs at a national and organizational level.
The study was conducted as a 3-round Delphi consensus survey in 2020. The electronic survey was based on a comprehensive inventory of international and national MR procedures in various settings. Expert panelists (N=41) independently assessed which topics should be documented in a structured form in EHRs. The interprofessional panel (N=41) consisted of 12 physicians, 13 pharmacists, 10 nurses, and 6 information management professionals (participation rate 66%-76% in rounds 1-3; consensus limit set at 80%). The responses were analyzed quantitatively and qualitatively.
Consensus was reached on 97.3% (108/111) of predetermined topics to be documented in a structured form in EHRs. Of these, 39 concerned the MR process, 25 related to potentially drug-induced symptoms, 11 related to burden of risks for adverse drug effects, 12 related to laboratory tests and other test results, 12 related to medication adherence, and 9 related to the use of intoxicants. The patient's blood pressure (mean 4.85, SD 0.53; on a Likert scale 1-5), kidney function (mean 4.81, SD 0.56), and risk of bleeding (mean 4.81, SD 0.56) were ranked as the 3 most important topics to be documented in a structured form. The panel reached a consensus that the information obtained from MRs should be made available to all health care professionals in the national digital repository for patient data and to patients to some extent.
The interprofessional expert panel strongly agreed on the results of the MRs that should be documented in a structured form in EHRs and made available to both health professionals involved in care teams and patients themselves.
电子健康记录（EHR）系统之间的数据传输不畅和缺乏互操作性一直是一个挑战，阻碍了临床实践中患者信息的可用性和实用性以及基于证据的决策。为了改善数据传输和互操作性，患者信息应以结构化格式记录。这也适用于与药物相关的患者信息以及干预措施的结果，如药物评估（MRs），以个别优化药物治疗方案，尤其是在老年人中。
本研究旨在确定在国家和组织层面，从药物评估中获得的哪些信息应在电子健康记录中以结构化形式记录。
该研究于2020年进行了三轮德尔菲共识调查。电子调查基于对各种环境中国际和国家药物评估程序的全面清单。专家小组成员（N = 41）独立评估哪些主题应在电子健康记录中以结构化形式记录。跨专业小组（N = 41）由12名医生、13名药剂师、10名护士和6名信息管理专业人员组成（第1 - 3轮的参与率为66% - 76%；共识限度设定为80%）。对回复进行了定量和定性分析。
对于应在电子健康记录中以结构化形式记录的预定主题，达成了97.3%（108/111）的共识。其中，39个与药物评估过程有关，25个与潜在的药物引起的症状有关，11个与药物不良反应的风险负担有关，12个与实验室检查和其他检查结果有关，12个与药物依从性有关，9个与 intoxicants 的使用有关。患者的血压（平均4.85，标准差0.53；李克特量表1 - 5）、肾功能（平均4.81，标准差0.56）和出血风险（平均4.81，标准差0.56）被列为应在结构化形式中记录的3个最重要主题。该小组达成共识，认为从药物评估中获得的信息应在国家患者数据数字存储库中提供给所有医疗保健专业人员，并在一定程度上提供给患者。
跨专业专家小组强烈同意应在电子健康记录中以结构化形式记录药物评估结果，并提供给护理团队中的医疗专业人员和患者本人。
