| Project/Area Number |
18K09964
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| Research Category |
Grant-in-Aid for Scientific Research (C)
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| Allocation Type | Multi-year Fund |
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| Section | 一般 |
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| Review Section |
Basic Section 58010:Medical management and medical sociology-related
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| Research Institution | University of Tsukuba |
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Principal Investigator |
OHARA MAKOTO 筑波大学, 医学医療系, 教授 (80194273)
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| Project Period (FY) |
2018-04-01 – 2021-03-31
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| Project Status |
Completed (Fiscal Year 2020)
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| Budget Amount *help |
¥2,340,000 (Direct Cost: ¥1,800,000、Indirect Cost: ¥540,000)
Fiscal Year 2020: ¥1,040,000 (Direct Cost: ¥800,000、Indirect Cost: ¥240,000)
Fiscal Year 2019: ¥390,000 (Direct Cost: ¥300,000、Indirect Cost: ¥90,000)
Fiscal Year 2018: ¥910,000 (Direct Cost: ¥700,000、Indirect Cost: ¥210,000)
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| Keywords | 医療の質 / 電子カルテ / 分析ツール / 医療の質の評価 / BIツール / 量的評価 / 診療録記載量 / 診療録監査 / 診療録の定量的分析 / システム開発 / 連携テスト / 電子カルテシステム / 医療の質の向上 |
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| Outline of Final Research Achievements |
For the purpose of verifying whether the POMR description method is appropriate for "electronic health record", I have developed a quantitative evaluation tool for the amount of description in electronic health records, especially the doctor's Assessment description.
As a result, A tool for extracting the amount and interval of description by doctor, department, and description item was developed from the data warehouse. It was found that there was a peculiar tendency in the description interval, the description frequency, and the amount of the description by the internal medicine departments, the surgical departments, or the medical department respectively. This indicates that direct quantity analysis of electronic health record description is useful from a different perspective from conventional visual medical record audits, and it is considered that thereby, an index for evaluating the quality of medical care can be presented in an automated form.
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| Academic Significance and Societal Importance of the Research Achievements |
診療録の記載方法は、問題志向型診療録（problem-oriented medical record）で行うことが主流であり、特に臨床研修教育病院などで広く実施されている。しかしながら、この記載方法は、紙カルテにおいては、非常に有効であったが「電子カルテ」運用の下では、必ずしも有効ではないことが、この研究により開発された記載を定量的に分析するツールにより判明しつつある。さらに従来の目視による診療録監査と異なる視点での診療録監査がこのツールで可能であることが示唆され、医師がリアルタイムで自身の記載について確認できるこのツールがより医療の質を向上させる電子カルテの構築に寄与すると考えられた。
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