Computerization of the essential clinic record to health primary care: a tool to support the family health strategy teams / Informatização do registro clínico essencial para a atenção primária à saúde: um instrumento de apoio às equipes da estratégia saúde da família

AUTOR(ES)
DATA DE PUBLICAÇÃO

2009

RESUMO

INTRODUCTION: Primary healthcare is the major portal of entry into organized health systems. In this setting attention to given not only to analysis of health risks characterized by classified diseases but also to social and emotional factors. The Brazilian public healthcare system (Sistema Único de Saúde - SUS) has utilized this integrated model since its inception in 1990. Family and community medicine is the specialty of Primary Care and is compatible with these principles. However, clinical education, often based on a dominance of clinical secondary and tertiary care with a strong bias towards experimental biomedicine has a strong influence over the manner in which clinical events are registered and coded. These factors can create limitations to data registry and is often inadequate to encompass the complex environment which is encountered in the day to day experience of the majority of patients encountered in Primary Care. The present work is based on the integration of the method of Weed of problem oriented medical record taking with an automation of clinical records and cardiovascular risk factor monitoring and management. We describe the results of the use of a software program for improving the essential clinical patient record during patient visits , including guided cardiovascular risk management surveillance. The software program is compatible with the principles of SUS, the Primary Care setting and the philosophy of Family Medicine. METHODS: In 2003, in an Primary Health Care ambulatory setting outpatients, 20 years or older, were either treated by care using the automated patient record including the riskfactor surveillance software (Intervention group, n= 616) or were treated following the standard practice protocols of their family physicians (Control Group, n=3577). At the end of the year patient outcomes and overall patient care costs were compared between the two groups. RESULTS: The average of the number of events (auxiliary tests, specialized referrals, and hospital admissions) decreased from 29.28 events per patient/year in the control group to 22.00 events per patient/year (p <0,001) in the intervention group. Similarly the cost per patient/year decreased from R$1,130.34 to R$611.51 (p <0.001), and the average cost per procedure decreased from R$25.96 to R$19.85 (p <0.001) for the control and intervention groups, respectively. CONCLUSIONS: Our results demonstrated that the use of an primary care automated clinical patient record, including a software program to automate cardiovascular risk factors guidelines, can decrease the number and cost of complementary exams, referrals to specialists, and hospital procedures arising from primary care consultations.

ASSUNTO(S)

custos de cuidados de saúde medicina de família e comunidade health care costs aderência a diretrizes clínicas family practice quality of health care qualidade da assistência à saúde primary health care medical records systems computerized atenção primária à saúde sistemas computadorizados de registros médicos guideline adherence

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