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医生对电子病历的使用:直接数据录入的问题与成效及医生工作效率

Physician use of electronic medical records: issues and successes with direct data entry and physician productivity.

作者信息

Clayton Paul D, Naus Scott P, Bowes Watson A, Madsen Tammy S, Wilcox Adam B, Orsmond Garth, Rocha Beatriz, Thornton Sidney N, Jones Spencer, Jacobsen Craig A, Udall Marc R, Rhodes Michael L, Wallace Brent E, Cannon Wayne, Gardner Jerry, Huff Stan M, Leckman Linda

机构信息

Intermountain Health Care and the Dept of Medical informatics at the University of Utah, Salt Lake City, Utah, USA.

出版信息

AMIA Annu Symp Proc. 2005;2005:141-5.

Abstract

At Intermountain Health Care, we evaluated whether physicians in an ambulatory setting will voluntarily choose to enter data directly into an electronic health record (EHR). In this paper we describe the benefits of an EHR, as they exist in the current IHC application and the ways in which we have sought to minimize obstacles to physician data entry. Currently, of 472 IHC employed physicians, 321 (68%) routinely enter some data directly into the EHR without coercion. Twenty-five percent (80/321) of the physicians use voice recognition for some data entry. Twelve of our 95 ambulatory clinics have voluntarily adopted measures to eliminate paper charts. Of the 212 physicians who entered data in 2004, sixty-nine physicians (22%) increased their level of data entry, while 12 (6%) decreased. We conclude that physicians will voluntarily adopt an EHR system, and will continue and even increase use after implementation barriers are addressed.

摘要

在山间医疗保健机构,我们评估了门诊环境中的医生是否会自愿选择直接将数据录入电子健康记录(EHR)。在本文中,我们描述了当前山间医疗保健机构应用中电子健康记录的益处,以及我们为尽量减少医生数据录入障碍所采取的方法。目前,在山间医疗保健机构聘用的472名医生中,有321名(68%)在没有强制要求的情况下常规地直接将一些数据录入电子健康记录。25%(80/321)的医生在一些数据录入中使用语音识别。我们95家门诊诊所中的12家已自愿采取措施消除纸质病历。在2004年录入数据的212名医生中,69名医生(22%)提高了数据录入水平,而12名医生(6%)降低了数据录入水平。我们得出结论,医生会自愿采用电子健康记录系统,并且在解决实施障碍后会继续甚至增加使用。

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