电子健康记录数据收集实践,以提升患者对口译服务偏好的标准化和互操作性:定性研究
Krysta Heaney-Huls1, Rida Shams1, Ruth Nwefo1
1NORC at the University of Chicago, Chicago, IL, United States.
Journal of medical Internet research
|January 31, 2025
概括
在电子健康记录中标准化收集患者的口译需求,提高了护理质量和公平的获取. 然而,缺乏数据标准阻碍了卫生系统之间的电子信息交换.
科学领域:
- 医疗信息学 医疗信息学
- 医疗保健服务研究 医疗服务研究
- 以患者为中心的护理
背景情况:
- 患有非英语语言偏好 (NELP) 的患者体验到更差的健康结果.
- 尽管需要越来越多的口译员,但口译员的使用率很低,这影响了护理质量.
- 标准化数据收集可以改善对语言辅助服务的访问.
研究的目的:
- 检查在电子健康记录 (EHR) 中收集和交换患者口译者偏好的做法.
- 评估对翻译需求的数据标准的实施成熟度.
- 识别用于标准化口译员数据的用例,挑战和机会.
主要方法:
- 进行了术语标准的叙述性审查,以记录电子健康记录中的口译者偏好.
- 与EHR开发者,卫生系统,临床医生和联邦机构举行了关键信息员讨论.
- 综合发现,以确定实施的差距和机会.
主要成果:
- 医疗机构认识到标准化收集患者语言辅助需求的价值.
- 确定的使用案例包括以人为中心的护理,护理过渡和医疗保健管理.
- 电子健康记录中存在解释器数据字段,但缺乏对标准术语 (例如,LOINC,SNOMED-CT) 的映射,限制了电子交换.
结论:
- 记录患者的口译者偏好可以提高服务质量,患者体验和健康公平.
- 常规收集解释需求发生,但缺乏标准化阻碍了数据交换.
- 推进标准化对于促进以患者为中心的护理和改善健康公平至关重要.
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