治疗师在电子医疗记录中实施腰部疼痛新记录实践的经验:采访研究
Anne Katrine Skjølstrup Toftdahl1, Stine Ibsen1, Louise Bilenberg Pape-Haugaard2
1Department of Physiotherapy, University College of Northern Denmark, Aalborg East, Denmark.
BMC research notes
|October 26, 2023
概括
治疗师发现实施新的电子健康记录 (EHR) 具有挑战性,在日常护理,质量评估和研究中面临数据质量和可用性方面的障碍. 成功采用EHR需要涉及治疗师和管理层.
科学领域:
- 医疗信息学 医疗信息学
- 改善临床实践的改善
- 治疗文档 治疗文档
背景情况:
- 临床实践随着新的指导方针,患者偏好和机构质量要求的发展而发展.
- 电子健康记录 (EHR) 是管理医疗保健提供这些变化的关键工具.
- 之前的干预措施旨在修改治疗师之间的腰部疼痛 (LBP) 的EHR文档实践.
研究的目的:
- 探索使用新实施的EHR系统的物理治疗师和职业治疗师的经验.
- 评估为腰部疼痛患者修改EHR文档实践的可行性.
- 在采用新的EHR文档标准时,识别促进者和障碍者.
主要方法:
- 一个定性描述性研究,涉及与治疗师的采访.
- 干预的重点是改变低背部疼痛 (LBP) 现有的EHR中的文档实践.
- 探索治疗师与新EHR系统的实践经验.
主要成果:
- 出现了三个关键主题:实施促进者/激励者,小组例行变化和成功的障碍.
- 成功实施EHR需要治疗师和管理层的参与.
- 在满足文档要求和实现足够的数据质量以供临床使用,质量评估和研究方面发现了重大困难.
结论:
- 在本研究中发现,开发一个有效地同时服务于治疗计划,质量评估和研究的EHR是不可行的.
- 进一步的研究是必要的,以解决EHR系统的复杂性设计和实施多方面的医疗保健需求.
- 让最终用户和管理层参与,对于在市级医疗保健机构成功采用EHR变更至关重要.
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