影响临床医生遵守诊断文件原则的因素:改进决策的概念映射方法。

Nafiseh Hosseini, Sayyed Mostafa Mostafavi, Kazem Zendehdel, Saeid Eslami
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引用次数: 5

摘要

背景:电子健康记录(EHRs)数据的质量取决于临床医生对诊断文件原则的依从性。目的:采用概念映射(CM)方法提取与控制电子病历数据质量的临床医生文件质量相关的因素。方法:将头脑风暴会议中提取的影响因素按参与者个体进行分类,采用多维标度和聚类分析对分类后的影响因素进行定量分析。最后,采用问卷调查的方法对提取因子的重要性和可行性进行分析。结果通过聚类图和Go-Zone图可视化。结果:因素被分为7类:“关于国际疾病分类和临床编码的知识”、“对辅助人员和指南的需求”、“解释问题的重要性和定义责任”、“其他人员的合作”、“编纂法律要求”、“工作量”和“临床障碍”,按重要性排序。结论:提高EHR数据质量,需要医生、护士、管理人员和EHR开发人员之间的协作。CM是实现这一目标的一种可接受的方法。我们的研究结果强调了临床编码知识的重要性,对其重要性和适用性的认识以及结构良好的信息系统的使用。结合起来,这三个因素可以对电子病历数据的质量产生强烈的积极影响。启示:根据本研究的结果,为政策制定者提供了一系列解决方案,并提出了两项干预措施,包括采用纳入文件指南的电子病历。我们进一步建议更新临床培训计划和监测和反馈机制,以促进电子病历记录过程。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Factors affecting clinicians' adherence to principles of diagnosis documentation: A concept mapping approach for improved decision-making.

Background: The quality of data in electronic health records (EHRs) depends on adherence of clinicians to principles of diagnosis documentation.

Objective: A concept mapping (CM) approach was used to extract factors related to quality of clinicians' documentation that govern EHR data quality.

Method: Influential factors extracted from brainstorming sessions were sorted by individual participants, followed by a quantitative analysis using multidimensional scaling and cluster analysis to categorise sorted factors. Finally, a questionnaire was used to elicit the importance-feasibility of the extracted factors. Results were visualised by cluster maps and Go-Zone plots.

Result: Factors were classified into seven clusters: "knowledge about International Classification of Diseases and clinical coding," "need for facilitators and guidelines," "explaining the importance of the issue and defining responsibilities," "cooperation of other personnel," "codify legal requirements," "workload" and "clinical obstacles," as ranked by importance.

Conclusion: To enhance the quality of EHR data, a collaboration between physicians, nurses, managers and EHR developers is required. CM is an acceptable approach to meet this objective. Our findings highlight the significance of clinical coding knowledge, awareness about its importance and applicability and use of well-structured information systems. In combination, these three factors can have a strong positive impact on the quality of EHR data.

Implications: A list of solutions is provided for policymakers, and two interventions suggested, based on the findings of this study, including the adoption of EHRs that incorporate documentation guidelines. We further propose updated clinical training programs and a monitoring and feedback mechanism to facilitate the EHR documentation process.

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