Kurihara Yukio, Fujii Hideaki
Kochi Medical School, Kochi University, Nankoku, Japan.
Stud Health Technol Inform. 2013;192:1025.
Most electronic medical record (EMR) systems in Japan are equipped with nursing documentation functions. Electronic nursing records (ENRs) are much more accessible to doctors and paramedical staff than paper-based record systems. Face-to-face communication might be used less often to acquire patient information collected by nurses if EMR systems were effectively used. We conducted a questionnaire survey to investigate the methods used by other health professionals to acquire patient information collected by nurses under EMR implementation at two university hospitals. There were 153 responses, which showed that 51% of doctors and 16% of paramedical staff still often used face-to-face communication even though more than 70% of them often accessed the ENR. Only 35% of doctors and paramedical staff recognized that the EMR system helped reduce the time needed to acquire patient information; furthermore, 32% thought that using the EMR system to acquire patient information was bothersome. These results indicate that the operability of EMR systems is still insufficient for health professionals.
日本的大多数电子病历（EMR）系统都具备护理记录功能。与纸质记录系统相比，医生和医护辅助人员更易获取电子护理记录（ENR）。如果能有效使用EMR系统，获取护士收集的患者信息时可能就较少使用面对面沟通了。我们开展了一项问卷调查，以调查在两家大学医院实施EMR的情况下，其他医疗专业人员获取护士收集的患者信息所采用的方法。共收到153份回复，结果显示，即便超过70%的医生和医护辅助人员经常访问ENR，但仍有51%的医生和16%的医护辅助人员经常使用面对面沟通。只有35%的医生和医护辅助人员认为EMR系统有助于减少获取患者信息所需的时间；此外，32%的人认为使用EMR系统获取患者信息很麻烦。这些结果表明，EMR系统对于医疗专业人员而言，其可操作性仍然不足。
