ST-Audit: guideline-based automatic auditing of electronic patient records

Authors:
Cleo Zanella Billa;Jacques Wainer;Claudia Barsottini
Affiliations:
Institute of Computing, University of Campinas, Campinas, Brazil 13083-970;Institute of Computing, University of Campinas, Campinas, Brazil 13083-970;Department of Health Informatics, Federal University of Sao Paulo, Sao Paulo, Brazil 13083-970
Venue:
Journal of Intelligent Information Systems
Year:
2011

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Abstract

This work presents the ST-Audit system that audits a patient record for conformance to a particular clinical guideline. The system uses ST-Guide which models a guideline as a set of states and transitions. The audit system tries to find a path in the state/transition diagram that corresponds to the actions taken by the physician, taking into consideration issues such as the unavailability of all the data needed to evaluate the transitions. The system was used to audit an outpatient clinic regarding their procedure for hypertension treatment (using the VI JNC guideline for hypertension), and the results of the number of non-compliant actions were presented and discussed. A follow up auditing showed a small but statistically significant reduction on the number of non-compliant actions for patients treated after the first audit.