电子健康记录中的复制工具:感知,含义和未来方向
Sky Corby1, Joan S Ash2, Rebecca M Jungbauer2
1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, United States.
JMIR medical informatics
|December 19, 2025
概括
医疗保健提供者使用电子健康记录 (EHR) 复制工具以提高效率,但面临文档错误和道德伤害. 他们建议人工智能和更好的培训来改进EHR文档工具并降低风险.
科学领域:
- 医疗信息学 医疗信息学
- 医疗保健技术 技术 医疗保健 技术
- 临床文档 临床文档
背景情况:
- 电子健康记录 (EHR) 提供了效率,但可以增加文档负担.
- 复制和粘贴 (CP) 和复制转发 (CF) 工具用于减轻文档工作量.
- 对于CP/CF工具对用户的意想不到的后果尚不清楚.
研究的目的:
- 探索医疗保健提供者对EHR复制工具的看法和使用情况.
- 收集改善这些文档工具的建议.
主要方法:
- 在一个学术健康科学中心,与各种各样的医疗保健专业人员进行了半结构面试.
- 创新的传播 意想不到的后果理论指导了定性分析.
主要成果:
- 提供商重视CP/CF工具的效率和沟通.
- 负面的后果包括文档不准确,患者安全风险和由于组织压力的道德伤害.
- 改进建议包括人工智能集成和增强培训.
结论:
- 在EHR复制工具的感知效率及其相关风险之间存在着紧张关系.
- 这种紧张局势可能会导致提供者道德焦虑或受伤.
- 通过人工智能提高EHR能力和提供有针对性的教育是减少文档负担和道德困境的关键.
关键词:
健康工作人员的态度.转账-转账-转账-转账-转账-转账临床沟通 临床沟通临床文档 临床文档复制粘贴是复制粘贴的方法.电子文档是电子文档.电子健康记录是电子健康记录.人类因素 人类因素定性研究是指质量研究.更多相关视频
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