Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators.
Computerized provider documentation: findings and implications of a multisite study of clinicians and administrators.
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DOI：
10.1136/amiajnl-2012-000946
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发表时间：
2013-07
期刊：
影响因子：
--
通讯作者：
Hammond KW
中科院分区：
文献类型：
--
作者：
Embi PJ;Weir C;Efthimiadis EN;Thielke SM;Hedeen AN;Hammond KW
临床文档是医疗记录的核心，也是一系列医疗保健和业务流程的核心。随着电子健康记录采用的扩大，计算机化的提供者文档（CPD）越来越多地成为获取临床文档的主要手段。以往的持续专业发展研究侧重于特定的利益相关者群体和地点，往往限制了其范围和结论。为了解决这个问题，我们研究了来自美国多个地点的多个利益相关者群体。我们在五个退伍军人事务部的设施进行了14个焦点小组，有129名参与者（54名医生或从业人员，34名护士和37名管理人员）。调查人员定性分析结果的成绩单，开发的类别链接到数据，并确定紧急主题。出现了与继续专业发展有关的五大主题：沟通和协调;表达能力的控制和限制;信息提供和推理支持;工作流程的改变和中断;信任和信心问题。结果强调，文档与临床和管理工作流程紧密交织。三个利益相关者群体之间的看法不同，但在各设施的群体内保持一致。CPD极大地改变了文档流程，影响了临床理解，决策和跨多个群体的沟通。对简单、快速、结构化和受约束的文档的需求往往与对高度可靠和可检索信息的需求相冲突，以支持临床推理和工作流程。目前的持续专业发展系统，虽然总的来说比纸张好，但往往不能满足用户的需要，部分原因是它们是基于过时的“纸张图表”模式。这些调查结果应告知那些正在实施持续专业发展制度的人，以及今后更有效的持续专业发展制度的计划。
Clinical documentation is central to the medical record and so to a range of healthcare and business processes. As electronic health record adoption expands, computerized provider documentation (CPD) is increasingly the primary means of capturing clinical documentation. Previous CPD studies have focused on particular stakeholder groups and sites, often limiting their scope and conclusions. To address this, we studied multiple stakeholder groups from multiple sites across the USA. We conducted 14 focus groups at five Department of Veterans Affairs facilities with 129 participants (54 physicians or practitioners, 34 nurses, and 37 administrators). Investigators qualitatively analyzed resultant transcripts, developed categories linked to the data, and identified emergent themes. Five major themes related to CPD emerged: communication and coordination; control and limitations in expressivity; information availability and reasoning support; workflow alteration and disruption; and trust and confidence concerns. The results highlight that documentation intertwines tightly with clinical and administrative workflow. Perceptions differed between the three stakeholder groups but remained consistent within groups across facilities. CPD has dramatically changed documentation processes, impacting clinical understanding, decision-making, and communication across multiple groups. The need for easy and rapid, yet structured and constrained, documentation often conflicts with the need for highly reliable and retrievable information to support clinical reasoning and workflows. Current CPD systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated ‘paper-chart’ paradigm. These findings should inform those implementing CPD systems now and future plans for more effective CPD systems.
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发表时间：
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影响因子：
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