电子病历的采用：对学术性骨科医疗实践中效率、完整性和准确性的影响。
Electronic Medical Record Adoption: The Effect on Efficiency, Completeness, and Accuracy in an Academic Orthopaedic Practice.
作者信息
Hollenbeck S Matthew, Bomar James D, Wenger Dennis R, Yaszay Burt
机构信息
*Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, CA †Kansas Orthopaedic Center, Wichita, KS.
出版信息
J Pediatr Orthop. 2017 Sep;37(6):424-428. doi: 10.1097/BPO.0000000000000679.
INTRODUCTION
The electronic medical record (EMR) is the new platform for documenting health information. The purpose of this study is to evaluate the impact of the EMR on efficiency, completeness, accuracy, and surgeon attitude in the orthopaedic program of a training hospital.
METHODS
Sixty paper charts were compared with 60 EMRs. Pre-EMR and post-EMR billing data was used to determine outpatient clinic volume and the number of providers seeing patients per month. Completeness was evaluated by noting the presence of items from a predetermined list of clinical information pertinent to each diagnosis. Age and side of injury was used to evaluate note accuracy. A survey was used to evaluate surgeon's attitudes regarding the EMR.
RESULTS
There was no difference in monthly volume pre-EMR and post-EMR. There was an increase in the number of providers needed to see patients, equating to a 19% reduction in the number of patient visits per provider. The EMR was 1.3 times more likely to include pertinent clinical information. Both paper charts and the EMR were highly accurate. The surgeon attitude survey revealed concerns regarding clinic efficiency, increased "off-hours" record keeping, and decreased clinic teaching.
DISCUSSION
EMR is an important and essential component of medical care delivery. Record completion and accuracy were similar across medical record types. The use of EMR led to a 19% reduction in patients per provider. Creating the record in the clinic setting appears to detract from patient interaction, and resident/fellow education time. A more focused, specialty designed, EMR may be more efficient for an orthopaedic practice. Future EMR technology should allow a focused EMR designed for specialties that is efficient to create but that can be electronically converted into a "master record" that meets the needs of an associated larger organization.
LEVEL OF EVIDENCE
Level III-retrospective comparative study.
引言
电子病历（EMR）是记录健康信息的新平台。本研究的目的是评估电子病历对一家教学医院骨科项目的效率、完整性、准确性和外科医生态度的影响。
方法
将60份纸质病历与60份电子病历进行比较。使用电子病历实施前和实施后的计费数据来确定门诊量以及每月看诊患者的医疗服务提供者数量。通过记录与每个诊断相关的临床信息预定列表中的项目是否存在来评估完整性。使用年龄和损伤部位来评估记录的准确性。通过一项调查来评估外科医生对电子病历的态度。
结果
电子病历实施前后的月门诊量没有差异。看诊患者所需的医疗服务提供者数量有所增加，相当于每个医疗服务提供者的患者就诊次数减少了19%。电子病历包含相关临床信息的可能性高出1.3倍。纸质病历和电子病历的准确性都很高。外科医生态度调查显示，他们对门诊效率、增加的“非工作时间”记录保存以及门诊教学减少表示担忧。
讨论
电子病历是医疗服务提供的重要且必要组成部分。不同类型病历的记录完整性和准确性相似。使用电子病历导致每个医疗服务提供者的患者数量减少了19%。在门诊环境中创建记录似乎会减少与患者的互动以及住院医师/专科住院医生的教育时间。对于骨科实践而言，更具针对性、专门设计的电子病历可能会更高效。未来的电子病历技术应允许为专科设计一种针对性强的电子病历，这种病历创建起来高效，但可以电子方式转换为满足相关更大组织需求的“主记录”。
证据水平
三级——回顾性比较研究。
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