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全科医疗计算机系统有助于医学审计吗?

Do general practice computer systems assist in medical audit?

作者信息

Harriss C, Pringle M

机构信息

Department of General Practice, University of Nottingham, UK.

出版信息

Fam Pract. 1994 Mar;11(1):51-6. doi: 10.1093/fampra/11.1.51.

DOI:10.1093/fampra/11.1.51
PMID:8034153
Abstract

This study was designed to assess the capabilities of current general practice computer software to perform medical audit. A total of 43 general practice clinical software suppliers were asked to complete a questionnaire consisting of general questions concerning their systems' responses to 85 audit questions that a practice might wish to ask in the areas of quality of care and contractual compliance. It was assumed that all systems had full patient data. Fourteen installations representing 14 systems that had been randomly selected from the responders were visited to validate the suppliers' responses. Thirty-two (74%) suppliers responded to the questionnaire and they represented 7696 installations. One supplier marketed two distinct systems giving 33 systems for analysis. The majority (52%) of responding suppliers had between 0 and 50 installations. Many shortfalls in auditing capability were demonstrated, e.g. 24% of systems were unable to audit the clinical content of a patient review, 48% were unable to audit the numbers of acute and repeat prescriptions, 51% were unable to audit emergency admissions, 70% were unable to audit the length of time a drug had been prescribed for and 85% were unable to audit the continuity of patient care. Limitations in the ability to perform even basic medical audits were demonstrated among current general practice computer systems. These have implications for the development of medical audit. Seven (21%) of the systems had no facilities for statistical analysis including percentages and 8 (24%) had no graphical abilities.(ABSTRACT TRUNCATED AT 250 WORDS)

摘要

本研究旨在评估当前全科医疗计算机软件执行医疗审计的能力。共邀请了43家全科医疗临床软件供应商填写一份问卷,问卷包含一些一般性问题,涉及他们的系统对85个审计问题的回应,这些问题是诊所可能希望在医疗质量和合同合规领域提出的。假设所有系统都有完整的患者数据。从回复者中随机挑选了代表14个系统的14个安装点进行走访,以验证供应商的回答。32家(74%)供应商回复了问卷,他们代表了7696个安装点。一家供应商销售两种不同的系统,因此共有33个系统可供分析。大多数(52%)回复的供应商拥有的安装点数量在0到50个之间。研究表明,审计能力存在许多不足,例如,24%的系统无法审计患者复诊的临床内容,48%的系统无法审计急性和重复处方的数量,51%的系统无法审计急诊入院情况,70%的系统无法审计某种药物的处方时长,85%的系统无法审计患者护理的连续性。当前的全科医疗计算机系统在执行甚至基本医疗审计的能力方面存在局限。这些对医疗审计的发展有影响。7个(21%)系统没有包括百分比在内的统计分析功能,8个(24%)系统没有图形处理能力。(摘要截取自250词)

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