电子健康记录的实施:从免费诊所的角度进行质量保证评估

A. Asmussen, Paiva Cj, E. Hepner, A. Garibay, McCarroll Ml
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引用次数: 0

摘要

引言:2009年的《经济和临床健康健康信息技术法案》(HITECH Act),美国各地的诊所都有新的激励措施,以确保电子健康记录(EHR)的使用能够改善患者获得护理和健康结果的机会。方法:作为实施新EHR的质量改进项目,从2017年1月1日至2017年7月1日,重点关注四种诊断,以提高文件依从性和后续诊断测试:糖尿病(DM)、高血压(HTN)、充血性心力衰竭(CHF)和慢性肾脏病(CKD)。结果:共回顾了n=502份病历。在获取/记录指标方面,年龄、性别的符合率为100%;49%为种族/民族;16%的教育和雇主信息;25%的初级保健提供者;基于EHR中记录的第一次就诊的每次诊断,59%的权重和70%-93%的关键结果。结论:EHR提供了一个一致的平台,可以在以前没有获得的免费诊所中建立质量指标。通过建立这些基准,免费诊所可以调整和修改有意义的使用期望,即使它们不是必需的。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Electronic Health Record Implementation: A Quality Assurance Assessment from a Free Clinic Perspective
Introduction: The Health Information Technology for Economic and Clinical Health Act (HITECH Act) in 2009, clinics across the United States have new incentive to ensure that the use of the electronic health record (EHR) works to improve patient access to care and health outcomes. Methods: As a quality improvement project for implementing a new EHR, four diagnoses were focused on from 1/1/2017 to 7/1/2017 to improve documentation compliance and follow-up diagnostic tests: diabetes (DM), hypertension (HTN), congestive heart failure (CHF) and chronic kidney disease (CKD). Results: A total of n=502 patient charts were reviewed. The compliance percentage in capturing/documenting the metrics were 100% for age, gender; 49% race/ethnicity; 16% education and employer information; 25% primary care providers; 59% weight and 70%-93% key outcomes based on each diagnosis on the first visit documented in the EHR. Conclusions: The EHR provided a consistent platform to establish quality metrics in a free clinic not previously acquired. By establishing these benchmarks, a free clinic can adapt and modify meaningful use expectations even though they are not required.
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