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助力患者更健康、医生更舒心的电子健康记录创新。

Electronic health record innovations for healthier patients and happier doctors.

作者信息

Krist Alex H

机构信息

From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond.

出版信息

J Am Board Fam Med. 2015 May-Jun;28(3):299-302. doi: 10.3122/jabfm.2015.03.150097.

Abstract

This special issue explores a range of health information technology (HIT) issues that can help primary care practices and patients. Findings address the design of HIT systems, primarily electronic health records (EHRs), the utility of various functionalities, and implementation strategies that ensure the greatest value. The articles also remind us that, while HIT can support the delivery of care, it is not a panacea. To be effective, functionality needs to be relevant and timely for both the clinician and patient. Prompts and better documentation can improve care, and "prompt fatigue" is not inevitable. Information presented within EHRs needs to be actionable. There is an ongoing tension between information overload and the right-and helpful-information. Even the order of presentation of information can make a difference in the outcome. Whether supported by HIT or not, basic tenants of care, such as including the whole care team in trainings, communicating with other providers, and engaging patients, remain essential. The studies in this issue will prove useful for informatics developers, practices and health systems making HIT decisions, and care teams refining HIT to support the needs of their patients.

摘要

本期特刊探讨了一系列有助于基层医疗实践和患者的健康信息技术(HIT)问题。研究结果涉及HIT系统的设计,主要是电子健康记录(EHR)、各种功能的效用以及确保最大价值的实施策略。这些文章还提醒我们,虽然HIT可以支持医疗服务的提供,但它并非万灵药。要想发挥效用,功能需要对临床医生和患者都具有相关性和及时性。提示和更好的文档记录可以改善医疗服务,“提示疲劳”并非不可避免。EHR中呈现的信息需要具有可操作性。信息过载与正确且有用的信息之间一直存在矛盾。甚至信息的呈现顺序也会对结果产生影响。无论是否有HIT的支持,护理的基本原则,如让整个护理团队参与培训、与其他医疗服务提供者沟通以及让患者参与其中,仍然至关重要。本期的研究将证明对信息学开发者、做出HIT决策的医疗机构和卫生系统以及优化HIT以满足患者需求的护理团队很有用。

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