初级医疗机构中的哮喘电子病历：综合回顾
2010/12/17
摘要
背景：在初级医疗机构中，采用哮喘电子病历（EMR）可以增强质量管理、评价和哮喘监督。
目的：描述初级医疗机构中哮喘电子病历的现状、支持工具及其使用情况。
方法：对1996年至2008年发表的文献进行综合回顾，文献来自于Ovid MEDLINE、EMBASE和CINAHL数据库。检索关键词包括：哮喘、病历、电脑化、初级医疗机构、初级保健、家庭医生、家庭医疗、慢性疾病、COPD、肿瘤、糖尿病及心血管疾病。排除与概念、系统开发和来源（如急诊治疗和药物EMR）相关的文献。由2名作者对文献进行综述。
结果：共检索到309篇文献，76篇文献符合纳入标准。22%的文献针对哮喘，78%的文献针对初级医疗机构的其它慢性疾病和/或EMR总体状态。文献包含有不同的方法学、不同的讨论主题和数据价值。描述哮喘EMR的文献，常常提及决策支持工具（N=3）和/或使用情况（N=14），特别是评价预测死亡率、评价疾病严重程度及诊断及时性的能力。初级医疗机构未见有包含有效哮喘最小数据集的EMR。本综述主要讨论三个问题：状态（使用者的描述、功能性和是否采用的问题）、工具（决策支持工具以增强知识摄取）和使用（数据质量、提取和转归）。
结论：初级医疗机构中的关于哮喘的EMR应用较少，但不包括讨论决策支持工具及其使用情况。在初级医疗机构中整合更为有效的哮喘EMR（包括最小数据集、标准化术语和有效指标），能进一步提升治疗效果，有利于对疾病转归的监测。
（刘国梁 审校）
J Asthma. 2010 Oct;47(8):895-912.
Asthma electronic medical records in primary care: an integrative review.
Minard JP, Turcotte SE, Lougheed MD.
Department of Medicine, Division of Respirology, Queen’s University, Kingston, Ontario, Canada. minardj@KGH.KARI.NET
Abstract
BACKGROUND: Quality management, evaluation, and surveillance of asthma may be enhanced by access to and utilization of an asthma electronic medical record (EMR) in primary care.
PURPOSE: To describe the current status, support tools, and utility of asthma EMRs in primary care.
METHODS: An integrative review of the literature published between 1996 and 2008 was completed using Ovid MEDLINE, EMBASE, and CINAHL databases. Key search terms included asthma, medical records, computerized, primary health care, primary care, family physician, family practice, chronic disease, COPD, neoplasm, diabetes mellitus, and cardiovascular disease. Articles related to concepts, systems in development, and sources such as acute care and pharmacy EMRs were excluded. Each article was reviewed by two reviewers.
RESULTS: Of 309 articles identified, 76 met the inclusion criteria. Twenty-two percent were specific to asthma, 78% pertained to other chronic diseases and/or the overall status of an EMR in primary care. The literature varied in methodology, topics of discussion and value of data. Articles describing an asthma EMR most often reported on decision support tools (n = 3) and/or utility (n = 14), specifically the ability to predict mortality and assess severity and timeliness of diagnosis. A primary care EMR containing a validated asthma minimum data set was not found. Three themes emerged from the review: status (description of users, functionalities and adoption issues), tools (decision support tools to enhance knowledge uptake), and utility (data quality, extraction and outcomes).
CONCLUSIONS: There is a paucity of asthma elements in EMRs in primary care, with the exception of discussion of decision support tools and utility. Integration of a more robust asthma EMR in primary care, including a minimum data set, standardized terminology, and validated indicators, may further enhance care and enable outcomes monitoring
J Asthma. 2010 Oct;47(8):895-912.
背景：在初级医疗机构中，采用哮喘电子病历（EMR）可以增强质量管理、评价和哮喘监督。
目的：描述初级医疗机构中哮喘电子病历的现状、支持工具及其使用情况。
方法：对1996年至2008年发表的文献进行综合回顾，文献来自于Ovid MEDLINE、EMBASE和CINAHL数据库。检索关键词包括：哮喘、病历、电脑化、初级医疗机构、初级保健、家庭医生、家庭医疗、慢性疾病、COPD、肿瘤、糖尿病及心血管疾病。排除与概念、系统开发和来源（如急诊治疗和药物EMR）相关的文献。由2名作者对文献进行综述。
结果：共检索到309篇文献，76篇文献符合纳入标准。22%的文献针对哮喘，78%的文献针对初级医疗机构的其它慢性疾病和/或EMR总体状态。文献包含有不同的方法学、不同的讨论主题和数据价值。描述哮喘EMR的文献，常常提及决策支持工具（N=3）和/或使用情况（N=14），特别是评价预测死亡率、评价疾病严重程度及诊断及时性的能力。初级医疗机构未见有包含有效哮喘最小数据集的EMR。本综述主要讨论三个问题：状态（使用者的描述、功能性和是否采用的问题）、工具（决策支持工具以增强知识摄取）和使用（数据质量、提取和转归）。
结论：初级医疗机构中的关于哮喘的EMR应用较少，但不包括讨论决策支持工具及其使用情况。在初级医疗机构中整合更为有效的哮喘EMR（包括最小数据集、标准化术语和有效指标），能进一步提升治疗效果，有利于对疾病转归的监测。
（刘国梁 审校）
J Asthma. 2010 Oct;47(8):895-912.
Asthma electronic medical records in primary care: an integrative review.
Minard JP, Turcotte SE, Lougheed MD.
Department of Medicine, Division of Respirology, Queen’s University, Kingston, Ontario, Canada. minardj@KGH.KARI.NET
Abstract
BACKGROUND: Quality management, evaluation, and surveillance of asthma may be enhanced by access to and utilization of an asthma electronic medical record (EMR) in primary care.
PURPOSE: To describe the current status, support tools, and utility of asthma EMRs in primary care.
METHODS: An integrative review of the literature published between 1996 and 2008 was completed using Ovid MEDLINE, EMBASE, and CINAHL databases. Key search terms included asthma, medical records, computerized, primary health care, primary care, family physician, family practice, chronic disease, COPD, neoplasm, diabetes mellitus, and cardiovascular disease. Articles related to concepts, systems in development, and sources such as acute care and pharmacy EMRs were excluded. Each article was reviewed by two reviewers.
RESULTS: Of 309 articles identified, 76 met the inclusion criteria. Twenty-two percent were specific to asthma, 78% pertained to other chronic diseases and/or the overall status of an EMR in primary care. The literature varied in methodology, topics of discussion and value of data. Articles describing an asthma EMR most often reported on decision support tools (n = 3) and/or utility (n = 14), specifically the ability to predict mortality and assess severity and timeliness of diagnosis. A primary care EMR containing a validated asthma minimum data set was not found. Three themes emerged from the review: status (description of users, functionalities and adoption issues), tools (decision support tools to enhance knowledge uptake), and utility (data quality, extraction and outcomes).
CONCLUSIONS: There is a paucity of asthma elements in EMRs in primary care, with the exception of discussion of decision support tools and utility. Integration of a more robust asthma EMR in primary care, including a minimum data set, standardized terminology, and validated indicators, may further enhance care and enable outcomes monitoring
J Asthma. 2010 Oct;47(8):895-912.
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