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通过病历审查确定艾滋病门诊中医疗保健专业人员的信息需求。

Information needs of health care professionals in an AIDS outpatient clinic as determined by chart review.

作者信息

Giuse N B, Huber J T, Giuse D A, Brown C W, Bankowitz R A, Hunt S

机构信息

University of Pittsburgh, PA.

出版信息

J Am Med Inform Assoc. 1994 Sep-Oct;1(5):395-403. doi: 10.1136/jamia.1994.95153427.

Abstract

OBJECTIVE

To examine the information needs of health care professionals in HIV-related clinical encounters, and to determine the suitability of existing information sources to address those needs.

SETTING

HIV outpatient clinic.

PARTICIPANTS

Seven health care professionals with diverse training and patient care involvement.

METHODS

Based on patient charts describing 120 patient encounters, participants generated 266 clinical questions. Printed and on-line information sources were used to answer questions in two phases: using commonly available sources and using all available medical library sources.

MEASUREMENTS

The questions were divided into 16 categories by subject. The number of questions answered, their categories, the information source(s) providing answers, and the time required to answer questions were recorded for each phase.

RESULTS

Each participant generated an average of 3.8 clinical questions per chart. Five categories accounted for almost 75% of all questions; the treatment protocols/regimens category was most frequent (24%). A total of 245 questions (92%) were answered, requiring an average of 15 minutes per question. Most (87%) of the questions were answered via electronic sources, even though paper sources were consulted first.

CONCLUSIONS

The participating professionals showed considerable information needs. A combination of on-line and paper sources was necessary to provide the answers. The study suggests that present-day information sources are not entirely satisfactory for answering clinical questions generated by examining charts of HIV-infected patients.

摘要

目的

探讨医疗保健专业人员在与艾滋病相关的临床诊疗过程中的信息需求,并确定现有信息来源能否满足这些需求。

地点

艾滋病门诊。

参与者

七名接受过不同培训且参与患者护理工作的医疗保健专业人员。

方法

基于描述120次患者诊疗情况的病历,参与者提出了266个临床问题。分两个阶段使用印刷和在线信息来源回答问题:先使用常用来源,再使用所有可用的医学图书馆资源。

测量指标

问题按主题分为16类。记录每个阶段回答的问题数量、类别、提供答案的信息来源以及回答问题所需的时间。

结果

每位参与者平均每份病历提出3.8个临床问题。五类问题几乎占所有问题的75%;治疗方案/疗程类别最为常见(24%)。总共回答了245个问题(92%),每个问题平均需要15分钟。尽管首先查阅了纸质资料,但大多数问题(87%)是通过电子资源回答的。

结论

参与研究的专业人员显示出相当大的信息需求。需要结合在线和纸质资源来提供答案。该研究表明,当今的信息来源对于回答通过检查艾滋病感染患者病历所产生的临床问题并不完全令人满意。

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