Johnson Kevin B, Ravich William J, Cowan John A
Vanderbilt University Medical Center, 402 Eskind Biomedical Library, 2209 Garland Avenue, Nashville, TN 37232-8340, USA.
Int J Med Inform. 2004 Sep;73(9-10):665-74. doi: 10.1016/j.ijmedinf.2004.05.009.
Computer-based software to record histories, physical exams, and progress or procedure notes, known as computer-based documentation (CBD) software, has been touted as an important addition to the electronic health record. The functionality of CBD systems has remained static over the past 30 years, which may have contributed to the limited adoption of these tools. Early users of this technology, who have tried multiple products, may have insight into important features to be considered in next-generation CBD systems.
We conducted a cross-sectional, observational study of the clinical working group membership of the American Medical Informatics Association (AMIA) to generate a set of features that might improve adoption of next-generation systems. The study was conducted online over a 4-month period; 57% of the working group members completed the survey.
As anticipated, CBD tool use was higher (53%) in this population than in the US physician offices. The most common methods of data entry employed keyboard and mouse, with agreement that these modalities worked well. Many respondents had experience with pre-printed data collection forms before interacting with a CBD system. Respondents noted that CBD improved their ability to document large amounts of information, allowed timely sharing of information, enhanced patient care, and enhanced medical information with other clinicians (all P < 0.001). Respondents also noted some important but absent features in CBD, including the ability to add images, get help, and generate billing information.
The latest generation of CBD systems is being used successfully by early adopters, who find that these tools confer many advantages over the approaches to documentation that they replaced. These users provide insights that may improve successive generations of CBD tools. Additional surveys of CBD non-users and failed adopters will be necessary to provide other useful insights that can address barriers to the adoption of CBD by less computer literate physicians.
用于记录病史、体格检查以及病程或操作记录的计算机软件，即基于计算机的文档记录（CBD）软件，被视为电子健康记录的一项重要补充。在过去30年里，CBD系统的功能一直停滞不前，这可能是这些工具采用率有限的原因之一。该技术的早期使用者试用过多种产品，他们可能对下一代CBD系统应考虑的重要功能有深入见解。
我们对美国医学信息学会（AMIA）临床工作组成员进行了一项横断面观察性研究，以生成一组可能有助于提高下一代系统采用率的功能。该研究在4个月的时间里通过网络进行；57%的工作组成员完成了调查。
正如预期的那样，该群体中CBD工具的使用率（53%）高于美国医生办公室。最常用的数据输入方法是使用键盘和鼠标，大家一致认为这些方式效果良好。许多受访者在使用CBD系统之前有使用预印数据收集表的经验。受访者指出，CBD提高了他们记录大量信息的能力，实现了信息的及时共享，改善了患者护理，并与其他临床医生加强了医学信息交流（所有P<0.001）。受访者还指出了CBD中一些重要但缺失的功能，包括添加图像、获取帮助以及生成计费信息的能力。
早期采用者成功地使用了最新一代的CBD系统，他们发现这些工具比被其取代的文档记录方法具有许多优势。这些使用者提供的见解可能会改进后续几代的CBD工具。有必要对CBD非使用者和采用失败的用户进行额外调查，以提供其他有用的见解，解决计算机知识较少的医生采用CBD的障碍。
