Lobach David F, Silvey Garry M, Macri Jennifer M, Hunt Megan, Kacmaz Roje O, Lee Paul P
Division of Clinical Informatics, Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA.
AMIA Annu Symp Proc. 2005;2005:465-9.
Supporting data entry by clinicians is considered one of the greatest challenges in implementing electronic health records. In this paper we describe a formative evaluation study using three different methodologies through which we identified obstacles to point-of-care data entry for eye care and then used the formative process to develop and test solutions to overcome these obstacles. The greatest obstacles were supporting free text annotation of clinical observations and accommodating the creation of detailed diagrams in multiple colors. To support free text entry, we arrived at an approach that captures an image of a free text note and associates this image with related data elements in an encounter note. The detailed diagrams included a color pallet that allowed changing pen color with a single stroke and also captured the diagrams as an image associated with related data elements. During observed sessions with simulated patients, these approaches satisfied the clinicians' documentation needs by capturing the full range of clinical complexity that arises in practice.
支持临床医生进行数据录入被认为是实施电子健康记录面临的最大挑战之一。在本文中，我们描述了一项形成性评估研究，该研究使用了三种不同的方法，通过这些方法我们确定了眼科护理即时护理数据录入的障碍，然后利用形成性过程来开发和测试克服这些障碍的解决方案。最大的障碍是支持对临床观察进行自由文本注释以及适应创建多种颜色的详细图表。为了支持自由文本录入，我们采用了一种方法，即捕获自由文本注释的图像，并将此图像与会诊记录中的相关数据元素相关联。详细图表包括一个调色板，允许通过单次笔触更改笔的颜色，并且还将图表捕获为与相关数据元素相关联的图像。在与模拟患者的观察过程中，这些方法通过捕获实践中出现的各种临床复杂性，满足了临床医生的记录需求。
