面向问题的文档:在商业电子健康记录中设计和广泛采用新工具包。

IF 2.5 Q2 HEALTH CARE SCIENCES & SERVICES
Richard L Altman, Chen-Tan Lin, Mark Earnest
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引用次数: 1

摘要

背景:问题导向文档是一种公认的笔记构建方法,有助于临床思维过程。然而,以问题为导向的文档在使用市售电子健康记录(EHR)系统的实践中是具有挑战性的。目的:我们的目标是在商业电子病历中创建、迭代和分发一个面向问题的文档工具包,最大限度地支持临床医生的思维,使用直观,并产生清晰的文档。材料和方法:我们采用迭代设计过程,强调视觉简洁、数据集成、可预测界面、数据重用和临床医生效率。创建面向问题的文档工具包需要使用ehr提供的工具和定制编程。结果:我们开发了一个以问题为导向的文档界面,其三列视图显示(1)访问诊断列表,(2)当前概述、评估和选定诊断的计划,以及(3)与该诊断相关的药物、实验室、数据和订单列表。我们还创建了一系列宏,将通过界面收集的信息输入到临床医生的笔记中。该工具包于2019年2月投入到实时环境中。在最初的9个月里,共有13个门诊部门的28名临床医生在8385次离散就诊中使用了定制的问题导向文档工具包。9个月后,我们卫生系统的上线教育和电子病历优化团队开始向电子病历的新老用户推广该工具包,结果门诊医生对该工具包的接受程度显著提高。仅在2022年4月,我们卫生系统271个部门的894名用户就使用了该工具包进行了92000多次门诊就诊。结论:作为商业电子病历的卫生系统客户,我们开发并部署了一个经过修订的面向问题的文档工具包,临床医生每月使用该工具包超过92,000次。关键的成功要素包括强调可用性和有效的培训努力。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Problem-oriented documentation: design and widespread adoption of a novel toolkit in a commercial electronic health record.

Problem-oriented documentation: design and widespread adoption of a novel toolkit in a commercial electronic health record.

Problem-oriented documentation: design and widespread adoption of a novel toolkit in a commercial electronic health record.

Problem-oriented documentation: design and widespread adoption of a novel toolkit in a commercial electronic health record.

Background: Problem-oriented documentation is an accepted method of note construction which facilitates clinical thought processes. However, problem-oriented documentation is challenging to put into practice using commercially available electronic health record (EHR) systems.

Objective: Our goal was to create, iterate, and distribute a problem-oriented documentation toolkit within a commercial EHR that maximally supported clinicians' thinking, was intuitive to use, and produced clear documentation.

Materials and methods: We used an iterative design process that stressed visual simplicity, data integration, a predictable interface, data reuse, and clinician efficiency. Creation of the problem-oriented documentation toolkit required the use of EHR-provided tools and custom programming.

Results: We developed a problem-oriented documentation interface with a 3-column view showing (1) a list of visit diagnoses, (2) the current overview and assessment and plan for a selected diagnosis, and (3) a list of medications, labs, data, and orders relevant to that diagnosis. We also created a series of macros to bring information collected through the interface into clinicians' notes. This toolkit was put into a live environment in February 2019. Over the first 9 months, the custom problem-oriented documentation toolkit was used in a total of 8385 discrete visits by 28 clinicians in 13 ambulatory departments. After 9 months, the go-live education and EHR optimization teams in our health system began promoting the toolkit to new and existing users of our EHR resulting in a significantly increased uptake by outpatient clinicians. In April 2022 alone, the toolkit was used in more than 92 000 ambulatory visits by 894 users in 271 departments across our health system.

Conclusions: As a health-system client of a commercial EHR, we developed and deployed a revised problem-oriented documentation toolkit that is used by clinicians more than 92 000 times a month. Key success elements include an emphasis on usability and an effective training effort.

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来源期刊
JAMIA Open
JAMIA Open Medicine-Health Informatics
CiteScore
4.10
自引率
4.80%
发文量
102
审稿时长
16 weeks
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