Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study.
Use of Simulation Based on an Electronic Health Records Environment to Evaluate the Structure and Accuracy of Notes Generated by Medical Scribes: Proof-of-Concept Study.
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DOI：
10.2196/medinform.7883
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发表时间：
2017-09-20
影响因子：
3.2
通讯作者：
Gold, Jeffrey A
中科院分区：
文献类型：
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作者：
Pranaat, Robert;Mohan, Vishnu;Gold, Jeffrey A
背景技术背景：越来越多地采用电子健康记录（EHR）与许多意想不到的负面影响提供者的效率和工作满意度。为了解决这个问题，使用医学抄写员来执行许多所需的EHR功能的情况急剧增加。尽管增长迅速，但很少有关于培训或评估工具的出版，以评估与电子健康记录相关的活动的安全性和有效性。鉴于有许多报告记录了其他专业团体在EHR接口和数据收集方面存在许多性能错误，抄写员可能面临类似的挑战。这突出了需要新的评估工具为medical scribes.Objective：本研究的目的是开发一个虚拟的基于视频的模拟演示和量化的变化和准确性的抄写员'转录笔记在电子病历。从一个部门的8名书记员中，共有5名女书记员，一心想从事卫生保健事业，至少有6个月的经验，被招募为我们的模拟研究。我们创建了三个模拟的患者-提供者场景。在我们的EHR模拟实例中，每个场景都包含相应的医疗记录。对于每一种情况，我们视频记录了一个标准化的患者-提供者的遭遇。招募了五名具有至少6个月EHR和模拟案例专业经验的抄写员。每个抄写员都观看了模拟的遭遇，并将笔记转录到模拟的EHR环境中。转录笔记进行了评价interscribe变异性，并与金标准的accuracy.RESULTS：所有抄写员完成了所有模拟的情况下。在音符结构和内容上存在显著的内部变异。总的来说，只有26%的数据元素是书写它们的抄写员所独有的。术语数据元素用于定义从模拟中感知的各个数据片段。通过计算三种情况下最长和最短音符之间的单词数量变化31%，37%和57%来确定音符长度，单词经济性范围在23%和71%之间。总的来说，有一个广泛的内部和内部的准确性变化为每个部分的笔记，范围从50%到76%，导致整体阳性预测值为38%和81%.CONCLUSIONS：我们创建了一个高保真，基于视频的EHR模拟，能够评估多个性能指标的医疗抄写员。在这个队列中，我们在临床文件的结构和准确性方面都表现出显着的变化。这种形式的模拟可以提供一个宝贵的工具，为未来的发展抄写课程和能力评估。
BACKGROUND: The increasing adoption of electronic health records (EHRs) has been associated with a number of unintended negative consequences with provider efficiency and job satisfaction. To address this, there has been a dramatic increase in the use of medical scribes to perform many of the required EHR functions. Despite this rapid growth, little has been published on the training or assessment tools to appraise the safety and efficacy of scribe-related EHR activities. Given the number of reports documenting that other professional groups suffer from a number of performance errors in EHR interface and data gathering, scribes likely face similar challenges. This highlights the need for new assessment tools for medical scribes.OBJECTIVE: The objective of this study was to develop a virtual video-based simulation to demonstrate and quantify the variability and accuracy of scribes' transcribed notes in the EHR.METHODS: From a pool of 8 scribes in one department, a total of 5 female scribes, intent on pursuing careers in health care, with at least 6 months of experience were recruited for our simulation study. We created three simulated patient-provider scenarios. Each scenario contained a corresponding medical record in our simulation instance of our EHR. For each scenario, we video-recorded a standardized patient-provider encounter. Five scribes with at least 6 months of experience both with our EHR and in the specialty of the simulated cases were recruited. Each scribe watched the simulated encounter and transcribed notes into a simulated EHR environment. Transcribed notes were evaluated for interscribe variability and compared with a gold standard for accuracy.RESULTS: All scribes completed all simulated cases. There was significant interscribe variability in note structure and content. Overall, only 26% of all data elements were unique to the scribe writing them. The term data element was used to define the individual pieces of data that scribes perceived from the simulation. Note length was determined by counting the number of words varied by 31%, 37%, and 57% between longest and shortest note between the three cases, and word economy ranged between 23% and 71%. Overall, there was a wide inter- and intrascribe variation in accuracy for each section of the notes with ranges from 50% to 76%, resulting in an overall positive predictive value for each note between 38% and 81%.CONCLUSIONS: We created a high-fidelity, video-based EHR simulation, capable of assessing multiple performance indicators in medical scribes. In this cohort, we demonstrate significant variability both in terms of structure and accuracy in clinical documentation. This form of simulation can provide a valuable tool for future development of scribe curriculum and assessment of competency.