Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey
Brainstorming about next-generation computer-based documentation: an AMIA clinical working group survey
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DOI：
10.1016/j.ijmedinf.2004.05.009
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发表时间：
2004-09-01
影响因子：
4.9
通讯作者：
Cowan, JA
中科院分区：
文献类型：
--
作者：
Johnson, KB;Ravich, WJ;Cowan, JA
用于记录病史、体检以及进展或手术记录的基于计算机的软件，称为基于计算机的文档 (CBD) 软件，被誉为电子健康记录的重要补充。 CBD 系统的功能在过去 30 年里一直保持不变，这可能导致这些工具的采用有限。该技术的早期用户尝试过多种产品，可能会深入了解下一代 CBD 系统中需要考虑的重要功能。目标和方法：我们对美国医学信息学协会 (AMIA) 的临床工作组成员资格进行了一项横断面观察性研究，以生成一组可能提高下一代系统采用率的功能。该研究在网上进行，历时 4 个月； 57% 的工作组成员完成了调查。结果：正如预期的那样，该人群中 CBD 工具的使用率 (53%) 高于美国医生办公室。最常见的数据输入方法是键盘和鼠标，人们一致认为这些方式效果很好。许多受访者在与 CBD 系统交互之前都有过预印数据收集表格的经验。受访者指出，CBD 提高了他们记录大量信息的能力，允许及时共享信息，增强患者护理，并增强与其他临床医生的医疗信息（所有 P < 0.001）。受访者还注意到 CBD 中一些重要但缺乏的功能，包括添加图像、获取帮助和生成咬合信息的能力。结论：最新一代 CBD 系统正在被早期采用者成功使用，他们发现这些工具比它们所取代的文档方法具有许多优势。这些用户提供的见解可能会改进连续几代 CBD 工具。有必要对 CBD 非用户和失败的采用者进行额外的调查，以提供其他有用的见解，从而解决计算机水平较低的医生采用 CBD 的障碍。 (C) 2004 Elsevier Ireland Ltd. 保留所有权利。
Computer-based software to record histories, physical exams, and progress or procedure notes, known as computer-based documentation (CBD) software, has been touted as an important addition to the electronic health record. The functionality of CBD systems has remained static over the past 30 years, which may have contributed to the limited adoption of these tools. Early users of this technology, who have tried multiple products, may have insight into important features to be considered in next-generation CBD systems. Objective and methods: We conducted a cross-sectional, observational study of the clinical working group membership of the American Medical Informatics Association (AMIA) to generate a set of features that might improve adoption of next-generation systems. The study was conducted online over a 4-month period; 57% of the working group members compteted the survey. Results: As anticipated, CBD tool use was higher (53%) in this population than in the US physician offices. The most common methods of data entry employed keyboard and mouse, with agreement that these modalities worked welt. Many respondents had experience with pre-printed data collection forms before interacting with a CBD system. Respondents noted that CBD improved their ability to document large amounts of information, allowed timely sharing of information, enhanced patient care, and enhanced medical information with other clinicians (all P < 0.001). Respondents also noted some important but absent features in CBD, including the ability to add images, get help, and generate bitting information. Conclusions: The latest generation of CBD systems is being used successfully by early adopters, who find that these tools confer many advantages over the approaches to documentation that they replaced. These users provide insights that may improve successive generations of CBD tools. Additional surveys of CBD non-users and failed adopters will be necessary to provide other useful insights that can address barriers to the adoption of CBD by less computer literate physicians. (C) 2004 Elsevier Ireland Ltd. All rights reserved.