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本文引用的文献

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Unraveling the IT productivity paradox--lessons for health care.解开信息技术生产力悖论——医疗保健领域的经验教训。
N Engl J Med. 2012 Jun 14;366(24):2243-5. doi: 10.1056/NEJMp1204980.
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The impact of the electronic medical record on structure, process, and outcomes within primary care: a systematic review of the evidence.电子病历对初级保健的结构、流程和结果的影响：系统评价证据。
J Am Med Inform Assoc. 2011 Nov-Dec;18(6):732-7. doi: 10.1136/amiajnl-2010-000019. Epub 2011 Jun 9.
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Electronic medical records and efficiency and productivity during office visits.电子病历与门诊就诊时的效率和生产力。
Am J Manag Care. 2011 Apr;17(4):296-303.
4
Computer assisted self interviewing in a sexual health clinic as part of routine clinical care; impact on service and patient and clinician views.计算机辅助自我访谈在性健康诊所作为常规临床护理的一部分；对服务和患者及临床医生观点的影响。
PLoS One. 2011 Mar 31;6(3):e18456. doi: 10.1371/journal.pone.0018456.
5
Physician productivity and the ambulatory EHR in a large academic multi-specialty physician group.在一个大型学术多专科医师集团中，医生的生产力和门诊电子病历。
Int J Med Inform. 2010 Jul;79(7):492-500. doi: 10.1016/j.ijmedinf.2010.04.006. Epub 2010 May 15.
6
Norwegians GPs' use of electronic patient record systems.挪威全科医生使用电子患者记录系统的情况。
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Electronic medical records--where to from here?电子病历——何去何从？
Aust Fam Physician. 2009 Jul;38(7):537-40.
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Productivity and cost implications of implementing electronic medical records into an ambulatory surgical subspecialty clinic.在门诊手术专科诊所实施电子病历的生产力和成本影响。
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Patients' perceptions of general practitioners using computers during the patient-doctor consultation.患者对全科医生在医患咨询过程中使用电脑的看法。
Health Inf Manag. 2005;34(1):8-12. doi: 10.1177/183335830503400104.
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Computers in the exam room: differences in physician-patient interaction may be due to physician experience.诊室中的电脑：医患互动的差异可能归因于医生的经验。
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大型城市基层医疗性健康中心的电子病历（EMR）评估。

Evaluation of Electronic Medical Record (EMR) at large urban primary care sexual health centre.

机构信息

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.

出版信息

PLoS One. 2013 Apr 4;8(4):e60636. doi: 10.1371/journal.pone.0060636. Print 2013.

DOI:10.1371/journal.pone.0060636
PMID:23593268
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC3617089/
Abstract

OBJECTIVE

Despite substantial investment in Electronic Medical Record (EMR) systems there has been little research to evaluate them. Our aim was to evaluate changes in efficiency and quality of services after the introduction of a purpose built EMR system, and to assess its acceptability by the doctors, nurses and patients using it.

METHODS

We compared a nine month period before and after the introduction of an EMR system in a large sexual health service, audited a sample of records in both periods and undertook anonymous surveys of both staff and patients.

RESULTS

There were 9,752 doctor consultations (in 5,512 consulting hours) in the Paper Medical Record (PMR) period and 9,145 doctor consultations (in 5,176 consulting hours in the EMR period eligible for inclusion in the analysis. There were 5% more consultations per hour seen by doctors in the EMR period compared to the PMR period (rate ratio = 1.05; 95% confidence interval, 1.02, 1.08) after adjusting for type of consultation. The qualitative evaluation of 300 records for each period showed no difference in quality (P>0.17). A survey of clinicians demonstrated that doctors and nurses preferred the EMR system (P<0.01) and a patient survey in each period showed no difference in satisfaction of their care (97% for PMR, 95% for EMR, P = 0.61).

CONCLUSION

The introduction of an integrated EMR improved efficiency while maintaining the quality of the patient record. The EMR was popular with staff and was not associated with a decline in patient satisfaction in the clinical care provided.

摘要

目的

尽管在电子病历 (EMR) 系统上投入了大量资金，但几乎没有研究对其进行评估。我们的目的是评估引入专门构建的 EMR 系统后服务效率和质量的变化，并评估使用该系统的医生、护士和患者对其的接受程度。

方法

我们比较了在大型性健康服务中引入 EMR 系统前后的九个月期间，审核了这两个时期的记录样本，并对员工和患者进行了匿名调查。

结果

在纸质病历 (PMR) 期间有 9752 次医生咨询（5512 个咨询小时），在 EMR 期间有 9145 次医生咨询（5176 个咨询小时符合纳入分析的条件。与 PMR 期间相比，EMR 期间每位医生的咨询量增加了 5%（调整后率比 = 1.05；95%置信区间，1.02，1.08）。对每个时期的 300 份记录进行的定性评估显示，质量没有差异（P>0.17）。对临床医生进行的调查表明，医生和护士更喜欢 EMR 系统（P<0.01），而在每个时期进行的患者调查显示，他们对护理的满意度没有差异（PMR 为 97%，EMR 为 95%，P=0.61）。

结论

引入集成的 EMR 提高了效率，同时保持了患者记录的质量。该 EMR 受到员工的欢迎，并且与所提供的临床护理中患者满意度的下降无关。