评估与电子病历中的 "未知 "和虚构病人有关的实用性和挑战

IF 1.2 Q3 PATHOLOGY
Kai J. Rogers MD, PhD, John Blau MD, Matthew D. Krasowski MD, PhD
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引用次数: 0

摘要

电子病历(EMR)允许在 EMR 生产环境中创建 "虚构 "的未知病人。令人惊讶的是,有关这些病人的使用案例或与他们在 EMR 中的存在相关的挑战的文献却很少。在这里,我们确定了本机构经常使用的三类病人:在生产环境中用于测试 EMR 功能的具有医疗记录编号(MRN)的真实虚构病人、用于存储敏感数据的 "保密病人",以及在紧急情况下被分配临时 MRN 直至获得更多信息的 "未知 "病人。此外,还探讨了未知病人一旦被确认后,合并其记录的另一层复杂性。从临床实验室的角度来看,每一类病人,无论是真实的还是虚构的,都会带来各种各样的挑战,而这些挑战通常都是根据具体情况来处理的。在此,我们将介绍一系列教学案例,这些案例改编自本机构实际发生的患者安全事件,涉及虚构、保密和未知的患者记录。这些说明性案例强调了这些虚构和未知患者的实用性,以及它们在机构和个人层面带来的挑战,包括从临时 MRNs 到已识别病历的临床数据合并过程中出现的问题。最后,我们就如何最好地管理可能出现的类似情况提出了建议。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Evaluating the utility and challenges associated with “unknown” and fictional patients in the electronic medical record

Electronic medical records (EMRs) allow for the creation of “fictional” and unknown patients within the EMR production environment. Surprisingly, there is sparse literature regarding the use cases for these patients or the challenges associated with their existence in the EMR. Here, we identified three classes of patients in regular use at our institution: true fictional patients with medical record numbers (MRNs) used to test EMR functions in the production environment, “confidential patients” used to store sensitive data, and “unknown” patients that are assigned temporary MRNs in emergency situations until additional information can be acquired. A further layer of complexity involving the merging of records for unknown patients once they are identified is also explored. Each class of patients, real or fictional, poses a variety of challenges from a clinical laboratory standpoint, which are often dealt with on a case-by-case basis. Here, we present a series of instructional cases adapted from actual patient safety events at our institution involving fictional, confidential, and unknown patient records. These illustrative cases highlight the utility of these fictional and unknown patients, as well as the challenges they pose on an institutional and individual level, including issues that arise from merging clinical data from temporary MRNs to identified patient charts. Lastly, we provide recommendations on how best to manage similar scenarios that may arise.

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来源期刊
Academic Pathology
Academic Pathology PATHOLOGY-
CiteScore
2.20
自引率
20.00%
发文量
46
审稿时长
15 weeks
期刊介绍: Academic Pathology is an open access journal sponsored by the Association of Pathology Chairs, established to give voice to the innovations in leadership and management of academic departments of Pathology. These innovations may have impact across the breadth of pathology and laboratory medicine practice. Academic Pathology addresses methods for improving patient care (clinical informatics, genomic testing and data management, lab automation, electronic health record integration, and annotate biorepositories); best practices in inter-professional clinical partnerships; innovative pedagogical approaches to medical education and educational program evaluation in pathology; models for training academic pathologists and advancing academic career development; administrative and organizational models supporting the discipline; and leadership development in academic medical centers, health systems, and other relevant venues. Intended authorship and audiences for Academic Pathology are international and reach beyond academic pathology itself, including but not limited to healthcare providers, educators, researchers, and policy-makers.
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