Kuilboer M M, van der Lei J, Bohnen A M, van Bemmel J H
Department of Medical Informatics, Erasmus University Rotterdam, The Netherlands.
Proc AMIA Annu Fall Symp. 1997:749-53.
Currently, developers of decision-support systems try to integrate these systems with the electronic medical record. The drawback is a limited amount of recorded medical data. System developers who face the choice between designing an integrated 'non-inquisitive' system and an integrated 'inquisitive' system need insight into the availability of information that is being missed by the support system. Therefore, we have investigated in a simulation study, the reasons why information that was being missed from the electronic medical records of patients with asthma/COPD by reviewers, had not been recorded by general practitioners. Important reasons were: the physicians had not recorded the information explicitly, they assumed the requested information to be common knowledge, and the information was available elsewhere in the electronic medical record. Also, we investigated the reasons why information that was being missed, could not be made available by the physicians. Important reasons were: the decision had been made by another decision maker, or the physician had not recorded the information at the time of the encounter. In addition to insight into the availability of missing information, system developers need to have insight into the significance of this information for the quality of the decision support, before the final choice between a non-inquisitive and an inquisitive design can be made.
目前，决策支持系统的开发者试图将这些系统与电子病历集成。缺点是记录的医疗数据量有限。在设计集成的“非询问式”系统和集成的“询问式”系统之间面临选择的系统开发者，需要了解支持系统遗漏的信息的可获取情况。因此，我们在一项模拟研究中调查了哮喘/慢性阻塞性肺疾病患者电子病历中被审核者遗漏的信息未被全科医生记录的原因。重要原因包括：医生未明确记录信息、他们认为所要求的信息是常识，以及该信息在电子病历的其他地方可以获取。此外，我们还调查了遗漏的信息无法由医生提供的原因。重要原因包括：决策已由其他决策者做出，或者医生在会诊时未记录该信息。除了了解缺失信息的可获取情况外，在最终决定采用非询问式设计还是询问式设计之前，系统开发者还需要了解这些信息对决策支持质量的重要性。
