Development of quantitative measures to discriminate medical records sufficient for information sharing

2022 Fiscal Year Final Research Report

• Project/Area Number: 19K19347
• Research Category: Grant-in-Aid for Early-Career Scientists
• Allocation Type: Multi-year Fund
• Review Section: Basic Section 58010:Medical management and medical sociology-related
• Research Institution: University of Tsukuba
• Principal Investigator: Kagawa Rina 筑波大学, 医学医療系, 講師 (10824675)
• Project Period (FY): 2019-04-01 – 2023-03-31
• Keywords: EHR / clinical notes / document formalization

Outline of Final Research Achievements

We conducted a large-subject experiment with physicians, nurses, and other health care professionals that evaluated the usefulness of progress notes. The results showed that when physicians were encouraged to add the intervention intent (i.e., why the physician performed the intervention), the progress notes were significantly more useful by other health care professionals without increasing the burden on the describing physician.
In this study period, the scope was also extended from progress notes to cooking recipes and performance instruction documents. For each of these documents, we identified descriptions and arrangements that significantly increased the usefulness perceived by readers, and incorporated our findings into an authoring tool.

Free Research Field

医療情報学

Academic Significance and Societal Importance of the Research Achievements

チーム医療が根付く今日、医療施設内さらには医療施設間において、患者の罹患や緊急性などの診療情報の共通理解がより一層求められる。しかし、プログレスノートの記載内容は、1960年代から世界的に受け入れられた記載の枠組みのProblem Oriented Medical Record (POMR)に従っても記載には自由度が高く、定量的かつ詳細な質の評価はできなかった。本研究は記載内容の細部まで踏み込んだ定量的な指標を示した点で、医療現場の情報記録のあり方の議論の基盤として意義がある。