Borbolla Damian, Taft Teresa, Taber Peter, Weir Charlene R, Norlin Chuck, Kawamoto Kensaku, Fiol Guilherme Del
Department of Informatics, University of California, Irvine, Irvine, California, USA.
VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), Salt Lake City, UT.
AMIA Annu Symp Proc. 2018 Dec 5;2018:272-278. eCollection 2018.
Effective care coordination of children and youth with special health care needs (CYSHCN) is critical but challenging. To investigate clinicians' information-gathering strategies while preparing for visits with CYSHCN. Critical incident interviews with primary care physicians and care coordinators. Six themes emerged indicating 1) substantial reliance on the electronic health record; 2) a central role of the problem list in organizing and summarizing information; 3) Medical Home's central role in organizing clinical documentation; 4) universal need to integrate information from external records; 5) lack of well-organized and labeled encounter documentation; and 6) lack of tools reconcile medication lists. Our findings have important implications to the design of informatics tools to support information-gathering in the care of CYSHCN.
有效协调有特殊医疗需求的儿童和青少年（CYSHCN）的护理至关重要但具有挑战性。为了调查临床医生在准备与CYSHCN进行就诊时的信息收集策略。对初级保健医生和护理协调员进行关键事件访谈。出现了六个主题，表明1）对电子健康记录的大量依赖；2）问题清单在组织和汇总信息方面的核心作用；3）医疗之家在组织临床文档方面的核心作用；4）整合外部记录信息的普遍需求；5）缺乏组织良好且有标签的会诊文档；6）缺乏协调药物清单的工具。我们的研究结果对支持CYSHCN护理中信息收集的信息学工具设计具有重要意义。
