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面向诊断放射科医生的电子健康记录驱动工作流程

Electronic Health Record-Driven Workflow for Diagnostic Radiologists.

作者信息

Geeslin Matthew G, Gaskin Cree M

机构信息

Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia.

Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville, Virginia.

出版信息

J Am Coll Radiol. 2016 Jan;13(1):45-53. doi: 10.1016/j.jacr.2015.08.008. Epub 2015 Oct 23.

Abstract

In most settings, radiologists maintain a high-throughput practice in which efficiency is crucial. The conversion from film-based to digital study interpretation and data storage launched the era of PACS-driven workflow, leading to significant gains in speed. The advent of electronic health records improved radiologists' access to patient data; however, many still find this aspect of workflow to be relatively cumbersome. Nevertheless, the ability to guide a diagnostic interpretation with clinical information, beyond that provided in the examination indication, can add significantly to the specificity of a radiologist's interpretation. Responsibilities of the radiologist include, but are not limited to, protocoling examinations, interpreting studies, chart review, peer review, writing notes, placing orders, and communicating with referring providers. Most of the aforementioned activities are not PACS-centric and require a login to one or more additional applications. Consolidation of these tasks for completion through a single interface can simplify workflow, save time, and potentially reduce the incidence of errors. Here, the authors describe diagnostic radiology workflow that leverages the electronic health record to significantly add to a radiologist's ability to be part of the health care team, provide relevant interpretations, and improve efficiency and quality.

摘要

在大多数情况下,放射科医生保持着高效的工作模式,其中效率至关重要。从基于胶片到数字影像解读和数据存储的转变开启了PACS驱动的工作流程时代,带来了速度上的显著提升。电子健康记录的出现改善了放射科医生获取患者数据的途径;然而,许多人仍然觉得工作流程的这一方面相对繁琐。尽管如此,利用除检查指征中提供的信息之外的临床信息来指导诊断解读的能力,能够显著提高放射科医生解读的特异性。放射科医生的职责包括但不限于制定检查方案、解读影像、查阅病历、同行评审、书写报告、下达医嘱以及与转诊医生沟通。上述大多数活动并非以PACS为中心,需要登录一个或多个其他应用程序。通过单一界面整合这些任务以完成工作,可以简化工作流程、节省时间,并有可能降低错误发生率。在此,作者描述了利用电子健康记录的诊断放射学工作流程,这极大地增强了放射科医生作为医疗团队一员的能力,能够提供相关解读,并提高效率和质量。

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