Model development for EHR interdisciplinary information exchange of ICU common goals.
Model development for EHR interdisciplinary information exchange of ICU common goals.
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EHR跨学科信息交换ICU共同目标的模型开发。
DOI：
10.1016/j.ijmedinf.2010.09.009
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发表时间：
2011-08
影响因子：
4.9
通讯作者：
Currie L
中科院分区：
文献类型：
--
作者：
Collins SA;Bakken S;Vawdrey DK;Coiera E;Currie L
有效的跨学科患者信息交换是重症监护室（ICU）安全、高效和以患者为中心的护理的重要组成部分。患者护理的频繁切换、患者病情的高敏度以及可用数据量的增加使信息交换复杂化。言语交流会受到打断和时间限制的影响。为了补充口头沟通，许多icu依靠电子健康记录（EHRs）中的文档来减少遗漏和信息丢失的错误。本研究的目的是建立一个ICU共同目标的EHR跨学科信息交换模型。将分布式认知和临床交流空间的理论框架整合在一起，并使用了先前发表的口头信息交换分类。在神经血管ICU观察了59.5小时的跨学科查房，并与ICU护士和医生进行了5次访谈和1次焦点小组讨论。ICU现有的文件工具不足以记录护士和医生在目标导向的行动和互动中的协作决策和口头沟通。临床医生认为电子病历在信息检索方面效率低下，导致进一步依赖口头信息交换。该模型表明，电子病历应支持：1)信息工具用于明确记录目标、干预措施和评估，并提供事件和更新的综合和汇总信息输出；2)支持协作决策和患者安全双重检查的消息传递工具，这些工具目前在缺乏电子病历支持的情况下发生在护士和医生之间。
Effective interdisciplinary exchange of patient information is an essential component of safe, efficient, and patient–centered care in the intensive care unit (ICU). Frequent handoffs of patient care, high acuity of patient illness, and the increasing amount of available data complicate information exchange. Verbal communication can be affected by interruptions and time limitations. To supplement verbal communication, many ICUs rely on documentation in electronic health records (EHRs) to reduce errors of omission and information loss. The purpose of this study was to develop a model of EHR interdisciplinary information exchange of ICU common goals. The theoretical frameworks of distributed cognition and the clinical communication space were integrated and a previously published categorization of verbal information exchange was used. 59.5 hours of interdisciplinary rounds in a Neurovascular ICU were observed and five interviews and one focus group with ICU nurses and physicians were conducted. Current documentation tools in the ICU were not sufficient to capture the nurses' and physicians' collaborative decision-making and verbal communication of goal-directed actions and interactions. Clinicians perceived the EHR to be inefficient for information retrieval, leading to a further reliance on verbal information exchange. The model suggests that EHRs should support: 1) Information tools for the explicit documentation of goals, interventions, and assessments with synthesized and summarized information outputs of events and updates; and 2) Messaging tools that support collaborative decision-making and patient safety double checks that currently occur between nurses and physicians in the absence of EHR support.
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