Rule Adam, Goldstein Isaac H, Chiang Michael F, Hribar Michelle R
Medical Informatics & Clinical Epidemiology, Oregon Health & Science University.
Casey Eye Institute, Oregon Health & Science University.
Proc SIGCHI Conf Hum Factor Comput Syst. 2020 Apr;2020. doi: 10.1145/3313831.3376205.
As healthcare providers have transitioned from paper to electronic health records they have gained access to increasingly sophisticated documentation aids such as custom note templates. However, little is known about how providers use these aids. To address this gap, we examine how 48 ophthalmologists and their staff create and use - a customizable and composable form of note template - to document office visits across two years. In this case study, we find 1) content-importing phrases were used to document the vast majority of visits (95%), 2) most content imported by these phrases was structured data imported by data-links rather than boilerplate text, and 3) providers primarily used phrases they had created while staff largely used phrases created by other people. We conclude by discussing how framing clinical documentation as end-user programming can inform the design of electronic health records and other documentation systems mixing data and narrative text.
随着医疗服务提供者从纸质病历转向电子健康记录，他们能够使用越来越复杂的文档辅助工具，如自定义笔记模板。然而，对于提供者如何使用这些辅助工具却知之甚少。为了填补这一空白，我们研究了48位眼科医生及其工作人员如何创建和使用——一种可定制和可组合的笔记模板形式——来记录两年间的门诊情况。在这个案例研究中，我们发现：1）绝大多数就诊记录（95%）使用了内容导入短语；2）这些短语导入的大部分内容是通过数据链接导入的结构化数据，而非样板文本；3）提供者主要使用自己创建的短语，而工作人员则主要使用他人创建的短语。我们通过讨论将临床文档构建为终端用户编程如何为电子健康记录以及其他混合数据和叙述文本的文档系统的设计提供信息来得出结论。
