Department of Radiology, Massachusetts General Hospital, Boston, MA, United States.
JMIR Med Inform. 2014 Feb 28;2(1):e3. doi: 10.2196/medinform.3204.
Development of task-specific electronic medical record (EMR) searches and user interfaces has the potential to improve the efficiency and safety of health care while curbing rising costs. The development of such tools must be data-driven and guided by a strong understanding of practitioner information requirements with respect to specific clinical tasks or scenarios. To acquire this important data, this paper describes a model by which expert practitioners are leveraged to identify which components of the medical record are most relevant to a specific clinical task. We also describe the computer system that was created to efficiently implement this model of data gathering. The system extracts medical record data from the EMR of patients matching a given clinical scenario, de-identifies the data, breaks the data up into separate medical record items (eg, radiology reports, operative notes, laboratory results, etc), presents each individual medical record item to experts under the hypothetical of the given clinical scenario, and records the experts' ratings regarding the relevance of each medical record item to that specific clinical scenario or task. After an iterative process of data collection, these expert relevance ratings can then be pooled and used to design point-of-care EMR searches and user interfaces tailored to the task-specific needs of practitioners.
开发特定于任务的电子病历 (EMR) 搜索和用户界面有可能提高医疗保健的效率和安全性,同时控制成本的上升。此类工具的开发必须是数据驱动的,并以对特定临床任务或场景的从业者信息需求的深刻理解为指导。为了获取这些重要数据,本文介绍了一种利用专家从业者来确定病历中与特定临床任务最相关的部分的模型。我们还描述了创建的计算机系统,以有效地实施这种数据收集模型。该系统从与给定临床场景匹配的患者的 EMR 中提取病历数据,对数据进行去识别,将数据分解为单独的病历项目(例如放射学报告、手术记录、实验室结果等),根据给定的临床场景向专家呈现每个单独的病历项目,并记录专家对每个病历项目与特定临床场景或任务的相关性的评分。在数据收集的迭代过程之后,这些专家相关性评分可以被汇集并用于设计针对从业者特定任务需求的即时 EMR 搜索和用户界面。