建立结果审查系统：从纸质病历过渡的关键第一步。
Building a results review system: a critical first step in transitioning from paper medical records.
作者信息
Wilbright Wayne A, Marier Robert, Abrams Amir, Smith Luis, Tran Duc, Thriffiley Alan, Butler Michael K, Rigamer Elmore, Williams Clayton, Post Robert
机构信息
LSU Health Sciences Center, New Orleans, LA, USA.
出版信息
AMIA Annu Symp Proc. 2005;2005:819-23.
Electronic health records (EHRs) are valuable tools for efficiently delivering safe and effective care, yet the majority of providers continue to rely on paper based systems. Cost is a significant barrier to adoption. Providers unable to afford a comprehensive EHR may still be capable of taking a less costly first step toward improving quality and safety with less aggressive yet effective clinical information system strategies. We identified a single, clearly definable, clinical information need: Improving the delivery of results and reports. We built a results review system to improve the efficiency and reliability of access to clinical information for providers working in the New Orleans safety net for the under/uninsured. We measured provider satisfaction with clinical information delivery systems before and after implementation and analyzed the rate of adoption and ongoing system utilization. Providers expressed increased satisfaction, and showed rapid adoption and an ongoing high rate of utilization over time.
电子健康记录（EHRs）是高效提供安全有效护理的宝贵工具，但大多数医疗服务提供者仍依赖纸质系统。成本是采用电子健康记录的重大障碍。无力承担全面电子健康记录的医疗服务提供者仍可采取成本较低的第一步，通过不那么激进但有效的临床信息系统策略来提高质量和安全性。我们确定了一个单一、明确可定义的临床信息需求：改善检查结果和报告的传递。我们建立了一个结果审查系统，以提高在新奥尔良为未参保/无保险人群提供安全网服务的医疗服务提供者获取临床信息的效率和可靠性。我们在实施前后测量了医疗服务提供者对临床信息传递系统的满意度，并分析了采用率和系统持续使用率。医疗服务提供者表示满意度提高，并且随着时间的推移迅速采用并持续保持高使用率。
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