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临床医生会阅读我们的报告吗?将放射信息系统与电子病历整合:头两年的经验

Do clinicians read our reports? Integrating the radiology information system with the electronic patient record: experiences from the first 2 years.

作者信息

Hurlen Petter, Østbye Truls, Borthne Arne, Dahl Fredrik A, Gulbrandsen Pål

机构信息

Helse Sør-Øst Health Services Research Centre, Akershus University Hospital, Lørenskog, Norway.

出版信息

Eur Radiol. 2009 Jan;19(1):31-6. doi: 10.1007/s00330-008-1098-3. Epub 2008 Aug 6.

Abstract

This study aimed to determine how clinicians adapted to and utilized new routines for accessing radiology reports after the integration of an electronic patient record (EPR) with a radiology information system (RIS). Activity-related data describing the availability and receipt of radiology reports were collected from the EPR and the RIS over a period of 2 years. Twelve percent of the final radiology reports had not been opened 4 weeks after they had been entered into the EPR. For opened reports, the median time after a report was available in the EPR until it was first opened by a clinician was less than 1 h for preliminary reports and less than 4 h for final radiology reports. The use of radiology reports was stable during the second observation year. Some reports were not opened for professional as well as technical reasons. The integrated information systems offered a potential for improving routines related to the transmission of radiology reports. Clinicians did not fully take advantage of this potential in the 2 years after its introduction.

摘要

本研究旨在确定在电子病历(EPR)与放射信息系统(RIS)集成后,临床医生如何适应并利用获取放射学报告的新流程。在两年时间里,从EPR和RIS中收集了与放射学报告的可用性和接收情况相关的活动数据。在最终的放射学报告录入EPR四周后,有12%的报告未被打开。对于已打开的报告,从报告在EPR中可用到临床医生首次打开的中位时间,初步报告少于1小时,最终放射学报告少于4小时。在第二个观察年期间,放射学报告的使用情况稳定。一些报告由于专业和技术原因未被打开。集成信息系统为改进与放射学报告传输相关的流程提供了潜力。在引入后的两年里,临床医生并未充分利用这一潜力。

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