Wilson G A, McDonald C J, McCabe G P
Am J Public Health. 1982 Jul;72(7):698-702. doi: 10.2105/ajph.72.7.698.
We performed a randomized clinical trial of the effect of immediately printed summaries of a computerized medical record on physician test ordering rates in an Emergency Room setting. The computerized medical record contained medication history, the results of most diagnostic studies, an outpatient problem list, and inpatient and emergency room diagnoses. Physicians were presented with a printed summary of the patient's computerized record for study but not for control encounters. All other patient information was equally available to both kinds of encounters. All results were provided for one period of the study, designated T1. Due to a program error, summaries were printed without recent data during a period of the study, designated T2. Two-thirds of the visits were cared for by internists, one-third by surgeons. During T1, internists ordered an average of 3.2 tests, costing $34.91 for control visits, and 2.7 tests, costing $29.94 for study control visits (p less than .026). Surgeons also ordered fewer tests during study visits as compared to controls (1.32 vs 1.54) but the differences were not statistically significant. There was no significant effect on either medical or surgical test ordering during time period T2.
我们进行了一项随机临床试验，研究在急诊室环境中，即时打印的电子病历摘要对医生开检查单率的影响。电子病历包含用药史、大多数诊断检查结果、门诊问题清单以及住院和急诊诊断。在研究病例中，医生会收到患者电子病历的打印摘要以供参考，而对照病例则没有。两种病例均可平等获取所有其他患者信息。所有结果均针对研究的一个阶段（指定为T1）给出。由于程序错误，在研究的另一个阶段（指定为T2），打印的摘要中没有最新数据。三分之二的就诊由内科医生诊治，三分之一由外科医生诊治。在T1阶段，内科医生在对照就诊中平均开3.2项检查，费用为34.91美元，在研究就诊中平均开2.7项检查，费用为29.94美元（p<0.026）。与对照相比，外科医生在研究就诊中开出的检查也较少（1.32项对1.54项），但差异无统计学意义。在T2阶段，对内科或外科检查单的开具均无显著影响。
