Structured Data Entry in the Electronic Medical Record: Perspectives of Pediatric Specialty Physicians and Surgeons
Structured Data Entry in the Electronic Medical Record: Perspectives of Pediatric Specialty Physicians and Surgeons
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DOI：
10.1007/s10916-017-0716-5
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发表时间：
2017-05-01
影响因子：
5.3
通讯作者：
Chiang, George
中科院分区：
文献类型：
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作者：
Bush, Ruth A.;Kuelbs, Cynthia;Chiang, George
Epic电子病历（EHR）平台支持结构化数据输入系统（SDES），允许开发人员根据用户的输入创建高度定制的病历模板，以最大限度地提高数据完整性并标准化结构。在EHR中使用离散数据字段来捕获用于二次分析和流行病学研究的数据有许多潜在的优势，但从临床医生直接获取数据仍然是利用EHR进行二次使用的最大障碍之一。医生对SDES的抵抗是多因素的。基于技术接受和使用统一理论的35项问卷被用来测量25名儿科专科医生和外科医生对采用SDES进行临床记录的态度、促进作用和潜在激励。统计分析包括分类数据的卡方检验以及连续变量的独立样本t检验和方差分析。9个结构的平均得分主要表现为积极的医生对SDES的态度，而外科医生是中立的。与两个年龄较大的年龄组相比，40岁以下的人更有可能回答存在结构化入学的便利条件（p =.02）。儿科外科医生对SDES对性能的影响（p = 0.01）和社会影响的影响（p = 0.02）的积极性明显低于专科医生;但更一致的是，使用表格是自愿的（p = 0.02）。态度上的差异可能反映了医疗培训、临床实践工作流程和部门具体实践。确定的阻力表明，增加SDES采用的努力应该是针对学科的，而不是统一的方法。
The Epic electronic health record (EHR) platform supports structured data entry systems (SDES), which allow developers, with input from users, to create highly customized patient-record templates in order to maximize data completeness and to standardize structure. There are many potential advantages of using discrete data fields in the EHR to capture data for secondary analysis and epidemiological research, but direct data acquisition from clinicians remains one of the largest obstacles to leveraging the EHR for secondary use. Physician resistance to SDES ismultifactorial. A 35-item questionnaire based on Unified Theory of Acceptance and Use of Technology, was used to measure attitudes, facilitation, and potential incentives for adopting SDES for clinical documentation among 25 pediatric specialty physicians and surgeons. Statistical analysis included chi-square for categorical data as well as independent sample t-tests and analysis of variance for continuous variables. Mean scores of the nine constructs demonstrated primarily positive physician attitudes toward SDES, while the surgeons were neutral. Those under 40 were more likely to respond that facilitating conditions for structured entry existed as compared to the two older age groups (p =.02). Pediatric surgeons were significantly less positive than specialty physicians about SDES effects on Performance (p =.01) and the effect of Social Influence (p =.02); but in more agreement that use of forms was voluntary (p =.02). Attitudinal differences likely reflect medical training, clinical practice workflows, and division specific practices. Identified resistance indicate efforts to increase SDES adoption should be discipline-targeted rather than a uniform approach.