Taylor David N
Clinical Sciences, Texas Chiropractic College, Pasadena, Texas.
J Chiropr Humanit. 2017 Jan 18;24(1):31-40. doi: 10.1016/j.echu.2016.12.001. eCollection 2017 Dec.
The purpose of this study was to review the literature on current challenges and propose solutions for the optimal utilization of the electronic health records (EHRs) in chiropractic practice.
A search was performed in the PubMed, Index of Chiropractic Literature, and Current Index to Nursing and Allied Health Literature databases from November 2005 to February 2015. A combination of the following key words was used: , , , , , and . Articles were categorized into common problems and solutions. These were filtered by application to chiropractic or educational institutions.
The search resulted in 45 papers, which included case reports of EHR implementation, governmental insurance reports, commentaries, controlled studies, narrative reviews of past experiences with conversion from paper systems, and the implementation of EHRs in small offices and chiropractic offices. Minimal literature was found that directly related to chiropractic EHRs. Improper utilization, incorrect use of the software, faulty implementation, workflow burdens, financial considerations, and insufficient training were found to negatively affect the quality of the record.
Documentation errors are often innate in the EHR software. Improper utilization, insufficient training, or difficulty in integration of the EHR into the clinical office setting results in poor implementation of the electronic version of the clinical record. Solutions that may decrease documentation errors include EHR training, continued financial incentives, and appropriate implementation process and utilization of available software features.
本研究旨在回顾有关当前挑战的文献，并为脊椎按摩疗法实践中电子健康记录（EHR）的最佳利用提出解决方案。
于2005年11月至2015年2月在PubMed、脊椎按摩疗法文献索引和护理及联合健康文献当前索引数据库中进行检索。使用了以下关键词的组合：[此处原文缺失关键词内容]。文章被归类为常见问题和解决方案。这些文章通过应用于脊椎按摩疗法或教育机构进行筛选。
检索结果为45篇论文，其中包括电子健康记录实施的案例报告、政府保险报告、评论、对照研究、从纸质系统转换的过往经验的叙述性综述，以及小型办公室和脊椎按摩疗法办公室中电子健康记录的实施情况。发现与脊椎按摩疗法电子健康记录直接相关的文献极少。发现使用不当、软件使用错误、实施有误、工作流程负担、财务考量以及培训不足会对记录质量产生负面影响。
文档错误在电子健康记录软件中往往是固有的。电子健康记录使用不当、培训不足或难以融入临床办公室环境会导致临床记录电子版的实施不佳。可能减少文档错误的解决方案包括电子健康记录培训、持续的财务激励措施，以及适当的实施过程和对可用软件功能的利用。
