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Accuracy of an electronic problem list from primary care providers and specialists.
Luna, Daniel; Franco, Mariano; Plaza, Claudio; Otero, Carlos; Wassermann, Santiago; Gambarte, Maria Laura; Giunta, Diego; González Bernaldo de Quirós, Fernán.
Afiliación
  • Luna D; Health Informatics Department, Hospital Italiano de Buenos Aires, Argentina.
Stud Health Technol Inform ; 192: 417-21, 2013.
Article en En | MEDLINE | ID: mdl-23920588
Accurate patient problem lists in Electronic Health Records (EHRs) are valuable tools for improving the quality of care, communication among professionals, facilitating research, quality measurement and the implementation of clinical decision support systems. However, problem lists are frequently inaccurate and out-of-date, and use varies widely across providers. These deficiencies limit problem list benefits. We decided to check if accuracy of problem lists-assessed at a granular level of detail-registered in EHRs depended on the specialty of the physician (primary care providers vs. specialists), and in the event that such differences did occur, whether or not accuracy had also been affected by the work environment. By using registered problems and taking the generated clinical document, we designed a cross-sectional survey following the guidelines of the Clinical Document Architecture standard. Problems registered by primary care providers have a higher level of accuracy than those registered by specialists in all settings considered (emergency unit, inpatient and outpatient). The work environment also significantly affects the accuracy level of problems registered.
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Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Atención Primaria de Salud / Errores Médicos / Adhesión a Directriz / Registros de Salud Personal / Registros Electrónicos de Salud / Médicos de Atención Primaria Tipo de estudio: Diagnostic_studies / Evaluation_studies / Guideline / Prognostic_studies / Qualitative_research País/Región como asunto: America do sul / Argentina Idioma: En Revista: Stud Health Technol Inform Asunto de la revista: INFORMATICA MEDICA / PESQUISA EM SERVICOS DE SAUDE Año: 2013 Tipo del documento: Article País de afiliación: Argentina Pais de publicación: Países Bajos
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Colección: 01-internacional Base de datos: MEDLINE Asunto principal: Atención Primaria de Salud / Errores Médicos / Adhesión a Directriz / Registros de Salud Personal / Registros Electrónicos de Salud / Médicos de Atención Primaria Tipo de estudio: Diagnostic_studies / Evaluation_studies / Guideline / Prognostic_studies / Qualitative_research País/Región como asunto: America do sul / Argentina Idioma: En Revista: Stud Health Technol Inform Asunto de la revista: INFORMATICA MEDICA / PESQUISA EM SERVICOS DE SAUDE Año: 2013 Tipo del documento: Article País de afiliación: Argentina Pais de publicación: Países Bajos