Bell D S, Greenes R A
Harvard Medical School, Division of Health Sciences and Technology, Boston, Massachusetts.
Proc Annu Symp Comput Appl Med Care. 1994:216-22.
The UltraSTAR structured data entry system is now in routine use for reporting ultrasound studies at Brigham and Women's Hospital, having been used for 3722 reports in its first ten months of service. Reports entered through GUI-based forms are uploaded via HL7 to a radiology information system and distributed through a hospital network. UltraSTAR introduces collaborative reporting, in which nonmedical and medical staff collaborate to produce a single report for each patient visit. Performance of UltraSTAR was measured as user satisfaction, data entry time, report completeness, free text annotation rate, and referring-physician satisfaction with reports. Results show high satisfaction with UltraSTAR among radiologists and acceptance of the system among ultrasound technicians. Data entry times averaged 5.3 minutes per report. UltraSTAR reports were slightly more complete than comparable narrative reports. Free text annotations were needed in only 25.2% of all UltraSTAR reports. Referring physicians were neutral to slightly positive toward UltraSTAR's outline-format reports. UltraSTAR is successful at structured data entry despite somewhat long reporting times. Its success can be attributed to efficiencies from collaborative reporting and from integration with existing information systems. UltraSTAR shows that the advantages of structured data entry can outweigh its difficulties even before problems of data entry time and concept representation are solved.
UltraSTAR结构化数据录入系统目前在布莱根妇女医院已常规用于报告超声检查,在其投入使用的前十个月已用于3722份报告。通过基于图形用户界面的表单录入的报告通过HL7上传至放射信息系统,并通过医院网络分发。UltraSTAR引入了协作报告,即非医务人员和医务人员协作,为每位患者就诊生成一份单一报告。UltraSTAR的性能通过用户满意度、数据录入时间、报告完整性、自由文本注释率以及转诊医生对报告的满意度来衡量。结果显示,放射科医生对UltraSTAR高度满意,超声技师也接受该系统。每份报告的数据录入时间平均为5.3分钟。UltraSTAR报告比类似的叙述性报告略为完整。所有UltraSTAR报告中仅25.2%需要自由文本注释。转诊医生对UltraSTAR的大纲格式报告态度中立至略为积极。尽管报告时间有点长,但UltraSTAR在结构化数据录入方面很成功。其成功可归因于协作报告以及与现有信息系统集成所带来的效率提升。UltraSTAR表明,即使在数据录入时间和概念表示问题尚未解决之前,结构化数据录入的优势也可能超过其困难。