一致性是关键:初级保健中的文档分发和效率.
Nate C Apathy1, Joshua Biro2, A Jay Holmgren3
1Health Policy and Management, University of Maryland School of Public Health, College Park, MD 20742, United States.
概括
具有一致的日常记录习惯的初级保健临床医生更有效率. 偏离常规模式大大降低了笔记写作效率,突出了电子健康记录 (EHR) 文档常规的重要性.
科学领域:
- 医疗信息学 医疗信息学
- 临床工作流的优化 临床工作流优化
- 主要护理实践管理的管理.
背景情况:
- 电子健康记录 (EHR) 系统是现代初级保健的组成部分.
- 临床医生之间日常记录实践的变化是常见的.
- 了解文档模式对于提高效率和减少临床医生的负担至关重要.
研究的目的:
- 分析初级保健中日常记录模式的变化.
- 为了确定特定的模式,一致性和偏差是否与笔记写作效率有关.
- 在EHR文档中识别影响临床医生的效率的因素.
主要方法:
- 利用了498名临床医生的Oracle Cerner Advance的EHR活跃使用数据.
- 雇佣k-means集群,以确定8种不同的日常文档模式.
- 分析了文档模式,一致性,偏差和笔记写作效率之间的关系.
主要成果:
- 确定了8种不同的日常记录模式,其中3种常见模式占临床医生的80.6%.
- 临床医生具有高的一致性 (>80%的单一模式中的天数) 显示出显著更高的记录效率.
- 与临床医生的常规模式的偏离与文档效率下降有关.
结论:
- 在不同的日常文档模式中,效率存在实质性的差异.
- 临床医生层面的因素,特别是文档的一致性,是提高效率的关键.
- 组织领导人应该支持一致的日常记录实践,以减少负担.
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