基于电子病历六级标准建设门诊合理用药闭环管理模式

Closed-Loop Management Mode of Rational Drug Use Based on the Level-Six Standard of Electronic Medical Record System

目的:基于电子病历系统应用水平六级标准创建该院门诊合理用药闭环管理模式,旨在为门诊患者合理用药保驾护航,为智慧药学建设提供参考。方法:利用人工智能技术对医师开方、药师审核、药品调剂、处方点评等门诊合理用药各环节进行管理,建立符合国家电子病历六级标准的闭环体系。同时,回顾性分析该院闭环管理前(2023年3—5月)、闭环管理前后(2023年6—8月)门诊处方用药不合理率。结果:应用门诊合理用药闭环管理模式后,门诊处方用药不合理率为3.56%(40723/1145056),较管理前的4.57%(52681/1153154)降低了1.01%,差异有统计学意义(P<0.01);除遴选药品不适宜外,其他类型不适宜用药处方数均较管理前显著减少;门诊次均药品费用为146.20元,较管理前的158.35元减少了7.67%,有效改善了公立医院绩效考核指标。结论:该院建设的门诊合理用药闭环管理体系满足国家电子病历六级评级要求,能够规范医疗人员的工作流程,减少门诊不合理用药。

OBJECTIVE:To establish the closed-loop management mode of rational drug use in the hospital based on the level-six standard of electronic medical record system,so as to escort the rational drug use of outpatients and provide reference for the construction of intelligent pharmacy.METHODS:Artificial intelligence technology was used to manage all aspects of rational drug use in outpatient department,such as physician prescription,pharmacist review,drug dispensing and prescription review,the closed-loop system was established in line with the level-six standard of electronic medical record system.Meanwhile,the irrational rate of outpatient prescriptions before closed-loop management(from Mar.to May 2023)and after closed-loop management(from Jun.to Aug.2023)were analyzed retrospectively.RESULTS:After implementation of the closed-loop management mode of rational drug use in outpatient department,the irrational rate of outpatient prescriptions was 3.56%(40723/1145056),which was 1.01%lower than 4.57%(52681/1153154)before management,the difference was statistically significant(P<0.01).The number of prescriptions for other types of inappropriate drugs except for the selection of unsuitable drugs decreased significantly.The average drug cost per outpatient visit was 146.20 RMB,with a reduction of 7.67%compared with before management cost of 158.35 RMB,effectively improving the performance assessment indicators of public hospitals.CONCLUSIONS:The closed-loop management mode of rational drug use in outpatients established by the hospital meets the requirements of the level-six standard of electronic medical record system,which can standardize the work flow of medical personnel and reduce irrational drug use in outpatient department.