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The Computerized Medical Record as a Tool for Clinical Governance in Australian Primary Care

机译：计算机病历作为澳大利亚初级保健临床管理的工具

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Background Computerized medical records (CMR) are used in most Australian general practices. Although CMRs have the capacity to amalgamate and provide data to the clinician about their standard of care, there is little research on the way in which they may be used to support clinical governance: the process of ensuring quality and accountability that incorporates the obligation that patients are treated according to best evidence. Objective The objective of this study was to explore the capability, capacity, and acceptability of CMRs to support clinical governance. Methods We conducted a realist review of the role of seven CMR systems in implementing clinical governance, developing a four-level maturity model for the CMR. We took Australian primary care as the context, CMR to be the mechanism, and looked at outcomes for individual patients, localities, and for the population in terms of known evidence-based surrogates or true outcome measures. Results The lack of standardization of CMRs makes national and international benchmarking challenging. The use of the CMR was largely at level two of our maturity model, indicating a relatively simple system in which most of the process takes place outside of the CMR, and which has little capacity to support benchmarking, practice comparisons, and population-level activities. Although national standards for coding and projects for record access are proposed, they are not operationalized. Conclusions The current CMR systems can support clinical governance activities; however, unless the standardization and data quality issues are addressed, it will not be possible for current systems to work at higher levels.
机译：背景技术计算机病历（CMR）用于大多数澳大利亚的常规实践中。尽管CMR具有合并和向临床医生提供有关其护理标准的数据的能力，但很少有研究将其用于支持临床治理的方法：确保质量和问责制的过程包含了患者的义务根据最佳证据进行治疗。目的本研究的目的是探讨CMR支持临床治疗的能力，能力和可接受性。方法我们对7个CMR系统在实施临床治理中的作用进行了实在的回顾，并开发了CMR的四级成熟度模型。我们以澳大利亚的初级保健为背景，以CMR作为机制，并根据已知的循证医学替代品或真实的结果衡量指标，对单个患者，地区和人群的结果进行了研究。结果缺乏CMR的标准化使国内和国际基准测试面临挑战。 CMR的使用很大程度上处于我们成熟度模型的第二级，这表明该系统相对简单，其中大部分流程都发生在CMR之外，并且几乎没有能力支持基准测试，实践比较和人口级活动。尽管提出了编码标准和记录访问项目的国家标准，但它们尚未付诸实施。结论当前的CMR系统可以支持临床治理活动。但是，除非解决了标准化和数据质量问题，否则当前系统将无法在更高级别上工作。

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