Rule Adam, Rick Steven, Chiu Michael, Rios Phillip, Ashfaq Shazia, Calvitti Alan, Chan Wesley, Weibel Nadir, Agha Zia
UC San Diego, La Jolla, CA.
UC San Diego, La Jolla, CA; Veteran's Medical Research Foundation, San Diego, CA.
AMIA Annu Symp Proc. 2015 Nov 5;2015:1103-10. eCollection 2015.
Electronic Health Records (EHRs) have increased the utility and portability of health information by storing it in structured formats. However, EHRs separate this structured data from the rich, free-text descriptions of clinical notes. The ultimate objective of our research is to develop an interactive progress note that unifies entry, access, and retrieval of structured and unstructured health information. In this study we present the design and subsequent testing with eight clinicians of a core element of this envisioned note: free-text order entry. Clinicians saw this new order-entry paradigm as a way to save time and preserve data quality by reducing double-documentation. However, they wanted the prototype to recognize more diverse types of shorthand and apply default values to fields that remain fairly constant across orders, such as number of refills and pickup location. Future work will test more complex orders, such as cascading orders, with a broader range of clinicians.
电子健康记录（EHRs）通过以结构化格式存储健康信息，提高了健康信息的实用性和便携性。然而，EHRs将这种结构化数据与临床记录丰富的自由文本描述分离开来。我们研究的最终目标是开发一种交互式病程记录，将结构化和非结构化健康信息的录入、访问和检索统一起来。在本研究中，我们展示了这种设想记录的一个核心元素——自由文本医嘱录入的设计，并随后对八位临床医生进行了测试。临床医生将这种新的医嘱录入模式视为一种通过减少重复记录来节省时间和保持数据质量的方法。然而，他们希望该原型能够识别更多类型的速记，并将默认值应用于不同医嘱中相当固定的字段，如续方数量和取药地点。未来的工作将使用更广泛的临床医生群体测试更复杂的医嘱，如级联医嘱。
