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实施和采用一个基于订单的外科病例请求工具跨子专业诊所的实施和采用
Andrew Patrick Bain1,2, Alyssa Low3, Robert W Turer4,5
1Clinical Informatics Center, UT Southwestern Medical Center, Dallas, United States.
Applied clinical informatics
|March 24, 2025
概括
在外科诊所实施基于顺序的病例请求 (OBCR) 工具提高了效率和数据准确性. 该系统促进了较早的手术病例输入和加强了手术前规划,与传统方法相比减少了错误.
科学领域:
- 医疗信息学 医疗信息学
- 优化外科手术工作流程的优化
- 电子健康记录 (EHR) 系统
背景情况:
- 计算机化提供者订单输入 (CPOE) 是许多订单的标准,但其用于外科病例请求的使用记录较少.
- 现有的外科诊所工作流程对病例请求不一致,导致数据重复和外部存储.
- 这导致需要在EHR中建立一个标准化,集成的系统.
研究的目的:
- 评估供应商输入的基于订单的案例请求 (OBCR) 工具对数据输入效率的影响.
- 评估该工具是否能够为外科病例请求创建更全面的EHR审计轨道.
- 将OBCR工作流与外科诊所的传统方法进行比较.
主要方法:
- 一个基于顺序的病例请求 (OBCR) 工具在安全网医院系统的外科诊所中实施.
- 新的OBCR工作流程和现有的手动工作流程 (诊所经理创建病例) 都被分析了六个月.
- 他们比较了来自19家诊所158名外科医生创建的7226例手术病例的数据.
主要成果:
- 在创建的所有操作案例中,OBCR工具被用于63% (4,585) 的操作案例.
- 虽然OBCR增加了从案例创建到调度的时间 (12.0 vs 0.7 天),但它也增加了从创建到完成的时间 (35.4 到 54.6 天).
- 通过OBCR",取消病例"的比率显著下降 (1.9%与4.5%相比).
结论:
- 大多数外科诊所采用了OBCR工具,证明了它的实用性.
- OBCR促进了早期的手术病例进入,并改善了手术前规划,降低了空白率.
- 该系统增强了用于报告的数据收集,并确定了优化工作流程的领域.
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