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单一电子病历中可用的实验室数据工具概述。

Overview of laboratory data tools available in a single electronic medical record.

作者信息

Kudler Neil R, Pantanowitz Liron

机构信息

Department of Clinical Informatics, Baystate Medical Center, Tufts University School of Medicine, Springfield, MA, USA.

出版信息

J Pathol Inform. 2010 May 26;1:3. doi: 10.4103/2153-3539.63824.

Abstract

BACKGROUND

Laboratory data account for the bulk of data stored in any given electronic medical record (EMR). To best serve the user, electronic laboratory data needs to be flexible and customizable. Our aim was to determine the various ways in which laboratory data get utilized by clinicians in our health system's EMR.

METHOD

All electronic menus, tabs, flowsheets, notes and subsections within the EMR (Millennium v2007.13, Cerner Corporation, Kansas City, MO, US) were explored to determine how clinicians utilize discrete laboratory data.

RESULTS

LABORATORY DATA IN THE EMR WERE UTILIZED BY CLINICIANS IN FIVE DISTINCT WAYS: within flowsheets, their personal inbox (EMR messaging), with decision support tools, in the health maintenance tool, and when incorporating laboratory data into their clinical notes and letters.

CONCLUSIONS

Flexible electronic laboratory data in the EMR hava many advantages. Users can view, sort, pool, and appropriately route laboratory information to better support trend analyses, clinical decision making, and clinical charting. Laboratory data in the EMR can also be utilized to develop clinical decision support tools. Pathologists need to participate in the creation of these EMR tools in order to better support the appropriate utilization of laboratory information in the EMR.

摘要

背景

实验室数据占任何给定电子病历(EMR)中存储数据的大部分。为了更好地服务用户,电子实验室数据需要灵活且可定制。我们的目的是确定我们医疗系统的电子病历中临床医生使用实验室数据的各种方式。

方法

对电子病历(美国密苏里州堪萨斯城erner公司的Millennium v2007.13)中的所有电子菜单、标签、流程图、笔记和子部分进行了探索,以确定临床医生如何使用离散的实验室数据。

结果

电子病历中的实验室数据被临床医生以五种不同方式使用:在流程图中、在他们的个人收件箱(电子病历消息)中、与决策支持工具一起使用、在健康维护工具中以及在将实验室数据纳入他们的临床笔记和信件时。

结论

电子病历中灵活的电子实验室数据有许多优点。用户可以查看、排序、汇总并适当地传递实验室信息,以更好地支持趋势分析、临床决策和临床记录。电子病历中的实验室数据还可用于开发临床决策支持工具。病理学家需要参与这些电子病历工具的创建,以便更好地支持电子病历中实验室信息的适当利用。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/e5b6/2929542/0960156f6864/JPI-1-3-g001.jpg

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