通过实施电子病历改善门诊患者的临床文档记录。

Clinical documentation improvement for outpatients by implementing electronic medical records.

作者信息

Seto Ryoma, Inoue Toshitaka, Tsumura Hiroshi

机构信息

Division of Healthcare Informatics, Faculty of Healthcare, Tokyo Healthcare University, Tokyo, Japan.

Department of Social Welfare Science, Faculty of Health and Social Welfare Science, Nishikyushu University, Saga, Japan.

出版信息

Stud Health Technol Inform. 2014;201:102-7.

PMID:24943531

Abstract

This observational study was conducted before and after implementing an electronic medical record (EMR) system to evaluate the change in outpatient workflow by implementation of EMR and the effectiveness of clinical documentation improvement (CDI). The number of hours for patient care increased by 89.2% (p < .05) and the hours for writing medical records after consulting decreased after implementation of EMR by 27.3% (p < .01). Implementation of EMR reduced nurses' workload to handle medical records by 78.8 (p < .05) but not changed for physicians. The necessary change in the information management process occurred after using the CDI indicator. We recommend that the "working hours of health professionals" and "handling hours for information resources" should be used widely as CDI indicators to improve workflow when implementing EMR.

摘要

本观察性研究在实施电子病历（EMR）系统前后进行，以评估EMR实施对门诊工作流程的改变以及临床文档改进（CDI）的效果。实施EMR后，患者护理时间增加了89.2%（p <.05），会诊后书写病历的时间减少了27.3%（p <.01）。EMR的实施使护士处理病历的工作量减少了78.8（p <.05），但对医生而言没有变化。使用CDI指标后，信息管理流程发生了必要的改变。我们建议，在实施EMR时，应广泛使用“卫生专业人员的工作时间”和“信息资源处理时间”作为CDI指标来改善工作流程。