Department of Anesthesiology, Division of Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Crit Care Med. 2013 Jun;41(6):1502-10. doi: 10.1097/CCM.0b013e318287f0c0.
Information overload in electronic medical records can impede providers' ability to identify important clinical data and may contribute to medical error. An understanding of the information requirements of ICU providers will facilitate the development of information systems that prioritize the presentation of high-value data and reduce information overload. Our objective was to determine the clinical information needs of ICU physicians, compared to the data available within an electronic medical record.
Prospective observational study and retrospective chart review.
Three ICUs (surgical, medical, and mixed) at an academic referral center.
Newly admitted ICU patients and physicians (residents, fellows, and attending staff).
The clinical information used by physicians during the initial diagnosis and treatment of admitted patients was captured using a questionnaire. Clinical information concepts were ranked according to the frequency of reported use (primary outcome) and were compared to information availability in the electronic medical record (secondary outcome). Nine hundred twenty-five of 1,277 study questionnaires (408 patients) were completed. Fifty-one clinical information concepts were identified as being useful during ICU admission. A median (interquartile range) of 11 concepts (6-16) was used by physicians per patient admission encounter with four used greater than 50% of the time. Over 25% of the clinical data available in the electronic medical record was never used, and only 33% was used greater than 50% of the time by admitting physicians.
Physicians use a limited number of clinical information concepts at the time of patient admission to the ICU. The electronic medical record contains an abundance of unused data. Better electronic data management strategies are needed, including the priority display of frequently used clinical concepts within the electronic medical record, to improve the efficiency of ICU care.
电子病历中的信息过载可能会妨碍医务人员识别重要的临床数据，并可能导致医疗错误。了解 ICU 医务人员的信息需求将有助于开发信息系统，优先呈现高价值数据，减少信息过载。我们的目标是确定 ICU 医生的临床信息需求，与电子病历中可用的数据进行比较。
前瞻性观察研究和回顾性图表审查。
学术转诊中心的三个 ICU（外科、内科和混合）。
新入住 ICU 的患者和医生（住院医师、研究员和主治医生）。
使用问卷记录了医生在新入院患者初始诊断和治疗期间使用的临床信息。根据报告的使用频率对临床信息概念进行排名（主要结果），并与电子病历中的信息可用性进行比较（次要结果）。在 1277 份研究问卷中，有 925 份（408 名患者）完成了调查。在 ICU 入院期间，有 51 个临床信息概念被认为是有用的。每位患者入院时，医生使用的概念中位数（四分位距）为 11 个（6-16 个），其中 4 个概念的使用频率超过 50%。电子病历中可用的临床数据有超过 25%从未被使用过，只有 33%的临床数据被主治医生使用频率超过 50%。
医生在 ICU 患者入院时使用有限数量的临床信息概念。电子病历中包含大量未使用的数据。需要更好的电子数据管理策略，包括在电子病历中优先显示经常使用的临床概念，以提高 ICU 护理的效率。
