Impact of an electronic information system on physician workflow and data collection in the intensive care unit
Impact of an electronic information system on physician workflow and data collection in the intensive care unit
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DOI：
10.1007/s001340000777
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发表时间：
2001-01-01
影响因子：
38.9
通讯作者：
Singhaviranon, P
中科院分区：
文献类型：
--
作者：
Apkon, M;Singhaviranon, P
目的：验证以下假设：(1)使用电子临床信息系统(ECIS)整合信息处理任务可以减少手工完成这些任务的时间；(2)结构化数据输入鼓励生成更详细的记录和捕获特定数据元素，即使在自愿输入的情况下也是如此。设计：医疗记录任务期间的前瞻性观察时间分析。对手工或电子方式完成的临床病历进行回顾性分析。设置：一个学术医学中心内有11个床位的儿科重症监护病房。参与者：5名儿科重症监护内科主治医师。测量：比较手写和电子病历以确定：(1)输入数据或撰写笔记所花费的时间；(2)记录患者体检的描述符数；(3)用户对结构化或非结构化数据输入的偏好；(4)记录与营养支持相关的特定数据元素的频率。结果：记录时间因用户而异，但不是图表方法：使用ECIS记录所需时间减少13%，但这并不显著。电子文档比手写文档更详细，描述符比手写文档多50%(17.8+/-1.4vs11.6+/-1.4)，一些数据元素不是手写的：13%的电子文档记录了与营养补充剂相关的信息，但89份手写文档中没有一份。与手写相比，结构化输入可以鼓励记录特定的或其他未合并的数据元素，从而产生更详细的记录。这表明，用户界面和决策支持组件可能会影响临床的类型和复杂性。护理员记录的数据。
Objective: To test the hypotheses that: (1) integrating information processing tasks using an electronic clinical information system (ECIS) decreases time to complete these tasks by hand; and (2) structured data entry encourages generation of more detailed records and capture of specific data elements even when entry is voluntary.Design: Prospective observational time analysis during medical documentation tasks. Retrospective analysis of clinical documentation completed by hand or electronically.Setting: Eleven bed pediatric intensive care unit within an academic medical center.Participants: Five pediatric intensive care medicine attending physicians.Measurements: Compared handwritten and electronic documentation to determine: (1) time spent entering data or composing notes; (2) number of descriptors documenting patients' physical exams; (3) users' preferences for structured or unstructured data entry; (4) frequency of documenting specific data elements related to nutritional support.Results: Documentation time varied by user but not charting method: it took 13% less time to document using the ECIS but this was not significant. Electronic documents were more detailed than handwritten containing 50% more descriptors (17.8 +/- 1.4 vs 11.6 +/- 1.4) overall and some data elements that were not handwritten: information related to nutritional supplementation was recorded in 13% of electronic documents but in none of 89 handwritten documents.Conclusions: Electronic and handwritten documentation consumed equal amounts of time. Structured entry, compared to handwriting, may encourage recording of specific or otherwise unincorporated data elements resulting in a more detailed record. This suggests that user interfaces and decision support components may influence both the types and complexity of clinical. data recorded by caregivers.