探索医生对从自由文本过渡到结构化和标准化文档实践的双重观点:采访和参与者观察研究
Olga Golburean1, Rune Pedersen2, Line Melby3
1Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
JMIR formative research
|March 21, 2025
概括
医生逐渐采用了新的电子健康记录 (EHR) 系统,但自由文本仍然优先于结构化数据. 实施标准化模板和定制培训可以改善临床文档和数据交换.
科学领域:
- 医疗信息学 医疗信息学
- 医疗文件 医疗文件
- 人与计算机在医疗保健中的互动
背景情况:
- 有效的临床文档对于护理协调和提供至关重要.
- 尽管电子健康记录 (EHR) 已被广泛采用,但许多医生仍然使用纸质记录方法.
- 需要新的文档方法来优化EHR的好处,以获得护理点的访问和数据交换.
研究的目的:
- 评估向跨机构EHR系统过渡对医生记录实践的影响.
- 了解影响医生偏好自由文本与结构化和标准化文档的因素.
主要方法:
- 一项涉及参与者观察和与医生进行半结构面试的定性研究.
- 从2023年9月到2024年1月,在挪威的一所大学医院进行.
- 使用反射主题分析分析的数据.
主要成果:
- 医生们最初面临的挑战是新的EHR系统的复杂性,但通过经验和同行合作,医生们逐渐采用了新的流程.
- 虽然结构化文档增加了,但自由文本仍然是首选的,这导致对标准化数据的不信任.
- 医生发现模板对于例行程序是有益的,尽管他们经常用自由文本输入创建自己的模板.
结论:
- 医生采用新的文档流程受到社会和技术因素的影响,如经验,感知到的好处和系统可用性.
- 建议使用标准化或半标准化模板和定制化的培训计划,以提高文档一致性并促进EHR转换.
- 解决医生在模板中的自由文本偏好对于增强数据记录和遵守指南至关重要.
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