电子健康记录系统的使用和急症和重症监护护士临床医生的文档负担:一种混合方法研究
Hwayoung Cho1, Oliver T Nguyen2, Michael Weaver1
1College of Nursing, Department of Family, Community and Health System Science, University of Florida, Gainesville, FL 32610, United States.
Journal of the American Medical Informatics Association : JAMIA
|September 11, 2024
概括
由于可用性问题和非EHR因素,电子健康记录 (EHR) 文档对护士来说是负担. 改善EHR设计和工作流程集成对于减少护士文档负担至关重要.
科学领域:
- 护理信息学 护理信息学
- 医疗保健技术 技术 医疗保健 技术
- 人与计算机的交互
背景情况:
- 电子健康记录 (EHR) 是现代医疗保健提供不可或缺的一部分.
- 在EHR中护理文档是必不可少的,但往往被临床医生视为负担.
研究的目的:
- 检查电子健康记录 (EHR) 的使用情况,并确定导致急症和重症护理护士文件负担的因素.
- 评估关键EHR组件的感知可用性和有用性.
主要方法:
- 一个混合方法研究,以技术接受和使用的统一理论为指导.
- 分析EHR日志文件以识别高负载单位,随后进行护士采访和关于EHR组件可用性的调查.
- 使用感应/演编码分析的定性数据.
主要成果:
- 护士发现EHR文档繁,在各个组件 (如流程表,MAR,护理计划,笔记和导航器) 中都有不同的水平.
- 造成负担的关键因素包括非EHR因素 (人员,敏度) 和EHR可用性问题 (数据冗余,导航不良,输入繁).
- 流程表,护理计划和导航器的可用性低于MAR和Notes.
结论:
- 当前的EHR文档功能提出了挑战,导致护士文档负担增加,受工作流不对齐和数据重复的影响.
- 建议包括尽量减少冗余数据输入,改进视觉线索和整合决策支持.
- 解决方案必须解决电子病历的可用性和非电子病历因素,以有效减少护士的文档负担.
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