Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
Department of Healthcare Information and Management, Ming Chuan University, No 5, De-Ming Rd, Taoyuan, Taiwan.
BMC Med Inform Decis Mak. 2018 Nov 26;18(1):109. doi: 10.1186/s12911-018-0709-4.
With advancements in information technology, computerized physician order entry (CPOE) and electronic Medical Records (eMR), have become widely utilized in medical settings. The predominant mode of CPOE in Taiwan is free text entry (FTE). Dynamic structured data entry (DSDE) was introduced more recently, and has increasingly drawn attention from hospitals across Taiwan. This study assesses how DSDE compares to FTE for CPOE.
A quasi-experimental study was employed to investigate the time-savings, productivity, and efficiency effects of DSDE in an outpatient setting in the gynecological department of a major hospital in Taiwan. Trained female actor patients were employed in trials of both entry methods. Data were submitted to Shapiro-Wilk and Shapiro-Francia tests to assess normality, and then to paired t-tests to assess differences between DSDE and FTE.
Relative to FTE, the use of DSDE resulted in an average of 97% time saved and 55% more abundant and detailed content in medical records. In addition, for each clause entry in a medical record, the time saved is 133% for DSDE compared to FTE.
The results suggest that DSDE is a much more efficient and productive entry method for clinicians in hospital outpatient settings. Upgrading eMR systems to the DSDE format would benefit both patients and clinicians.
随着信息技术的进步,计算机化医嘱录入(CPOE)和电子病历(eMR)已在医疗环境中得到广泛应用。台湾主要采用自由文本录入(FTE)模式的 CPOE。最近引入了动态结构化数据录入(DSDE),并引起了全台湾医院的广泛关注。本研究评估了 DSDE 与 CPOE 的 FTE 相比的效果。
采用准实验研究,调查了台湾一家大医院妇科门诊环境中 DSDE 对医嘱录入时间节省、生产力和效率的影响。训练有素的女性演员患者参与了两种录入方法的试验。数据提交给 Shapiro-Wilk 和 Shapiro-Francia 检验以评估正态性,然后进行配对 t 检验以评估 DSDE 与 FTE 之间的差异。
与 FTE 相比,使用 DSDE 平均可节省 97%的时间,并使医疗记录中的内容更加丰富和详细 55%。此外,对于医疗记录中的每个条款录入,DSDE 比 FTE 节省的时间为 133%。
结果表明,DSDE 是医院门诊环境中临床医生更高效、更有生产力的录入方法。将电子病历系统升级到 DSDE 格式将使患者和临床医生都受益。