为自动化临床订单开发和应用所需数据
Sameh N Saleh1,2,3, Kevin B Johnson1,2
1Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA 19146, United States.
Journal of the American Medical Informatics Association : JAMIA
|September 23, 2025
概括
在电子健康记录 (EHR) 中自动化临床订单可以减少临床医生的负担并提高患者安全. 一个由8个需求的新框架有助于确定合适的自动化订单,增强认知支持和安全性.
科学领域:
- 临床信息学 临床信息学
- 卫生系统工程 卫生系统工程
- 医疗决策支持 医疗决策支持
背景情况:
- 电子健康记录 (EHR) 提供了自动化临床订单的潜力,以减少临床医生的工作量并提高患者安全.
- 需要一个结构化的框架来确保在自动化订单时的临床有效性,透明度和安全性.
研究的目的:
- 开发和验证一个需要的数据框架,以评估EHR中自动化临床订单的适当性.
- 用一个活体卫生系统数据集来证明这个框架的操作价值.
主要方法:
- 聚焦小组分析和文献审查以确定主题并开发所需数据.
- 临床调查以使用用例和利克特尺度验证所需数据.
- 分析了140万个基于订单的警报和4410万个使用过规则和关联规则挖掘的订单.
主要成果:
- 确定了8个需要:逻辑一致性,数据来源,订单透明度,上下文永久性,监控计划,触发一致性,护理团队赋权和系统问责制.
- 适当的使用案例在适当性,认知支持和患者安全方面得分明显高 (P < .001).
- 运营分析显示,每年可节省26.5个供应商小时的潜在时间,并确定了8000个额外适当订单的机会.
结论:
- 开发的需求数据与临床医生的看法保持一致,并为评估自动化订单提供了一个结构化的方法.
- 特定临床订单的自动化显示了改善认知支持的潜力,同时保持了患者的安全.
- 医疗保健系统应该利用这些需要的数据和数据挖掘来系统地识别和管理自动化订单.
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