Electronic Medical Record (EMR) Project Team, The Royal Children's Hospital Melbourne, VIC, Australia.
Electronic Medical Record (EMR) Project Team, The Royal Children's Hospital Melbourne, VIC, Australia.
Int J Med Inform. 2017 Dec;108:92-96. doi: 10.1016/j.ijmedinf.2017.10.009. Epub 2017 Oct 14.
Clinical medical handover between doctors forms a critical part of the patient care process. However, with the evolution of junior medical staff (JMS) working conditions, time pressure and increasing clinical and administrative loads mean that quality clinical handover is increasingly important yet more challenging to achieve. This study evaluated the impact of a newly integrated electronic handover tool on JMS adoption and usage of the tool, as well as impacts on the quality (accuracy and redundancy) of handover data, JMS perceived workflow (time management and communication) and JMS satisfaction.
The majority of JMS surveyed used the tool at 1 (87.0%) and 3 (67.4%) months post implementation. After the introduction of the electronic handover tool, 67.5% of users spent less than 15min updating handover data in the electronic handover tool, compared to just 6.7% prior to the introduction. 28.3% of respondents noted that there was >25% redundant data, compared to more than half (52.2%) prior to introduction of the electronic tool. Overall JMS satisfaction with their handover process was significantly higher post implementation of the integrated electronic handover report (17.4% pre, 80.4% at 1 month, 67.4% at 3 months).
A newly introduced integrated electronic medical record handover tool had a high uptake amongst JMS, and resulted in improvement in perceived handover efficiency, a reduction in redundant data entry and improved JMS handover satisfaction.
医生之间的临床医疗交接是患者护理过程的重要组成部分。然而,随着初级医务人员(JMS)工作条件的演变,时间压力以及临床和行政负担的增加,意味着高质量的临床交接变得越来越重要,但也越来越具有挑战性。本研究评估了新集成的电子交接工具对 JMS 采用和使用该工具的影响,以及对交接数据的质量(准确性和冗余性)、JMS 感知工作流程(时间管理和沟通)和 JMS 满意度的影响。
在实施后 1(87.0%)和 3(67.4%)个月,大多数 JMS 调查对象使用了该工具。在引入电子交接工具后,与引入之前相比,有 67.5%的用户在电子交接工具中更新交接数据的时间少于 15 分钟。与引入电子工具之前相比,有 28.3%的受访者指出存在>25%的冗余数据。整体而言,JMS 对接班过程的满意度在实施集成电子交接报告后显著提高(引入前为 17.4%,实施后 1 个月为 80.4%,实施后 3 个月为 67.4%)。
新引入的集成电子病历交接工具在 JMS 中得到了广泛采用,并提高了感知交接效率,减少了冗余数据录入,并提高了 JMS 交接满意度。