基于电子健康记录的干预对记录实践的影响
Shreya Shah1, Michael Bedgood2, Anna Devon-Sand1
1Stanford University School of Medicine, Stanford, California, United States.
Applied clinical informatics
|July 17, 2024
概括
新的电子健康记录 (EHR) 注释模板,在2021年评估和管理 (E&M) 编码更改后实施,略减少了文档的时间,但没有显著减少文档长度或医生的负担.
科学领域:
- 医疗信息学 医疗信息学
- 改善医疗保健质量 改善医疗保健质量
- 医生文档 医生的文档
背景情况:
- 医生疲劳严重加剧了广泛的文件要求.
- 2021年评估和管理 (E&M) 编码修订旨在减轻这种文档负担.
研究的目的:
- 评估新的电子健康记录 (EHR) 工具和文档最佳实践对提供者经验的影响.
- 在一个学术医疗中心分析文件长度的变化和在2021年E&M变化之后记录所花费的时间.
主要方法:
- 开发和实施了五种最佳实践和两个新的门诊笔记模板 (E&M和预防性访问).
- 通过使用5点利克特比例进行了提供者调查,并分析了未识别的EHR元数据 (Signal,Epic Systems).
- 在E&M变化之前 (2020年8月至12月) 和之后 (2021年8月至12月) 的时间框架之间比较了EHR指标,包括使用笔记模板的子组分析.
主要成果:
- 新票据模板的高采用率:31,480次E&M访问和1,464次预防性访问.
- 82%的调查回复率;55%的受访者认为E&M变化可以减少负担,但只有28%的人对记录所花费的时间感到满意.
- 每次预约笔记的时间显著减少 (p=0.004);整体文档长度没有显著变化 (p=0.45).
- 注释模板的使用与减少文档长度相关 (p=0.034).
结论:
- 2021年E&M变化和新的EHR工具显示,在文档时间和长度方面有所改善.
- 感知到的文档负担并没有显著改善,这表明需要进一步干预.
- 需要额外的工具和研究来有效地减少医生文件负担.
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