从电子健康记录收集护理数据的可行性,用于国家护理数据库:试点研究
Justin L Miller1, Gordon F West2, Judy A Orina3
1Madigan Army Medical Center, Tacoma, WA; School of Nursing, University of Alabama at Birmingham, Birmingham, AL.
Nursing outlook
|December 31, 2025
概括
从军事卫生系统电子健康记录 (EHR) 收集护理敏感指标 (NSI) 数据到国家护理数据库 (NND) 是可行的. 标准化EHR文档对于有效的数据提取和质量改进至关重要.
科学领域:
- 护理信息学 护理信息学
- 改善医疗保健质量 改善医疗保健质量
- 健康信息管理 管理健康信息
背景情况:
- 军事卫生系统 (MHS) 的电子健康记录 (EHR) 和国家护理数据库 (NND) 提供了提高单位和医院质量的潜力.
- 利用这些系统可以改善军事医疗机构的患者护理结果和运营效率.
研究的目的:
- 评估利用MHS EHR收集和提交护理敏感指标 (NSI) 数据到国家护理数据库 (NND) 的可行性.
- 评估EHR数据在护理中的质量指标的实际应用.
主要方法:
- 在两个军事医院进行了一项描述性研究,持续了12个月.
- 收集了28个护理敏感指标 (NSI),并提交给国家护理数据库 (NND).
- 参与的时间投资被记录在日志上,以量化资源分配.
主要成果:
- 在研究期间,确定了七种不同的数据收集方法.
- 从EHR中自动提取数据是最有效的方法,但由于文档的变化而面临限制.
- 手动数据提取,虽然更耗时,但是在单位和医院层面最常用的方法.
结论:
- 在EHR中标准化文档工作流程对于改善互操作性和实现高效的数据提取至关重要.
- 积极参与国家护理数据库 (NND) 促进了指标标准化,使设施能够对数据进行基准测试,并推动护理质量的提高.
- 将EHR数据与国家数据库集成,可以改善护理实践和患者的治疗结果.
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