J Am Med Inform Assoc - Method of electronic health record documentation and quality of primary care.

Tópicos

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Resumo

JECTIVE: Physicians who more intensively interact with electronic health records (EHRs) through their documentation style may pay greater attention to coded fields and clinical decision support and thus may deliver higher quality care. We measured the quality of care of physicians who used three predominating EHR documentation styles: dictation, structured documentation, and free text.METHODS: We conducted a retrospective analysis of visits by patients with coronary artery disease and diabetes to the Partners Primary Care Practice Based Research Network. The main outcome measures were 15 EHR-based coronary artery disease and diabetes measures assessed 30 days after primary care visits.RESULTS: During the 9-month study period, 7000 coronary artery disease and diabetes patients made 18569 visits to 234 primary care physicians of whom 20 (9%) predominantly dictated their notes, 68 (29%) predominantly used structured documentation, and 146 (62%) predominantly typed free text notes. In multivariable modeling adjusted for clustering by patient and physician, quality of care appeared significantly worse for dictators than for physicians using the other two documentation styles on three of 15 measures (antiplatelet medication, tobacco use documentation, and diabetic eye exam); better for structured documenters for three measures (blood pressure documentation, body mass index documentation, and diabetic foot exam); and better for free text documenters on one measure (influenza vaccination). There was no measure for which dictators had higher quality of care than physicians using the other two documentation styles.CONCLUSIONS: EHR-assessed quality is necessarily documentation-dependent, but physicians who dictated their notes appeared to have worse quality of care than physicians who used structured EHR documentation.CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT00235040.

Resumo Limpo

jectiv physician intens interact electron health record ehr document style may pay greater attent code field clinic decis support thus may deliv higher qualiti care measur qualiti care physician use three predomin ehr document style dictat structur document free textmethod conduct retrospect analysi visit patient coronari arteri diseas diabet partner primari care practic base research network main outcom measur ehrbas coronari arteri diseas diabet measur assess day primari care visitsresult month studi period coronari arteri diseas diabet patient made visit primari care physician predomin dictat note predomin use structur document predomin type free text note multivari model adjust cluster patient physician qualiti care appear signific wors dictat physician use two document style three measur antiplatelet medic tobacco use document diabet eye exam better structur document three measur blood pressur document bodi mass index document diabet foot exam better free text document one measur influenza vaccin measur dictat higher qualiti care physician use two document stylesconclus ehrassess qualiti necessarili documentationdepend physician dictat note appear wors qualiti care physician use structur ehr documentationclin trial registr number clinicaltrialsgov identifi nct

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