Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States.
Information Technology Entity Services and Corporate Information Services, University of Pennsylvania Health System, Philadelphia, Pennsylvania, United States.
Methods Inf Med. 2021 May;60(1-02):32-48. doi: 10.1055/s-0041-1731784. Epub 2021 Jul 19.
The electronic health record (EHR) has become increasingly ubiquitous. At the same time, health professionals have been turning to this resource for access to data that is needed for the delivery of health care and for clinical research. There is little doubt that the EHR has made both of these functions easier than earlier days when we relied on paper-based clinical records. Coupled with modern database and data warehouse systems, high-speed networks, and the ability to share clinical data with others are large number of challenges that arguably limit the optimal use of the EHR OBJECTIVES: Our goal was to provide an exhaustive reference for those who use the EHR in clinical and research contexts, but also for health information systems professionals as they design, implement, and maintain EHR systems.
This study includes a panel of 24 biomedical informatics researchers, information technology professionals, and clinicians, all of whom have extensive experience in design, implementation, and maintenance of EHR systems, or in using the EHR as clinicians or researchers. All members of the panel are affiliated with Penn Medicine at the University of Pennsylvania and have experience with a variety of different EHR platforms and systems and how they have evolved over time.
Each of the authors has shared their knowledge and experience in using the EHR in a suite of 20 short essays, each representing a specific challenge and classified according to a functional hierarchy of interlocking facets such as usability and usefulness, data quality, standards, governance, data integration, clinical care, and clinical research.
We provide here a set of perspectives on the challenges posed by the EHR to clinical and research users.
电子健康记录 (EHR) 已经变得越来越普及。与此同时，医疗专业人员也开始利用这一资源获取医疗服务和临床研究所需的数据。毫无疑问，EHR 使得这两个功能比以前依赖纸质临床记录的日子更加容易。结合现代数据库和数据仓库系统、高速网络以及与他人共享临床数据的能力，带来了许多挑战，这些挑战限制了 EHR 的最佳使用。
我们的目标是为在临床和研究环境中使用 EHR 的人提供详尽的参考，同时也为设计、实施和维护 EHR 系统的健康信息系统专业人员提供参考。
本研究包括一个由 24 名生物医学信息学研究人员、信息技术专业人员和临床医生组成的小组，他们都在 EHR 系统的设计、实施和维护方面拥有丰富的经验，或者在作为临床医生或研究人员使用 EHR 方面拥有丰富的经验。小组的所有成员都隶属于宾夕法尼亚大学宾夕法尼亚医学院，并且都有使用各种不同的 EHR 平台和系统的经验，以及它们随时间的演变。
每位作者都在 20 篇短文集中分享了他们在使用 EHR 方面的知识和经验，每篇短文都代表了一个具体的挑战，并根据互锁方面的功能层次结构进行分类，例如可用性和有用性、数据质量、标准、治理、数据集成、临床护理和临床研究。
我们在这里提供了一套关于 EHR 给临床和研究用户带来的挑战的观点。
