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首页> 外文会议>International Conference on Information Technology in Medicine and Education >The Evaluation of a Wizard-Based Outpatient EMR in Oral and Maxilla Facial Surgery Department From the Aspects of Documentation Time and Record Quality — A Randomized, Cross-over Study
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The Evaluation of a Wizard-Based Outpatient EMR in Oral and Maxilla Facial Surgery Department From the Aspects of Documentation Time and Record Quality — A Randomized, Cross-over Study

机译：从记录时间和记录质量的角度评估口腔颌面外科基于向导的门诊电子病历—一项随机交叉研究

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Background: The electronic medical records(EMR) have been widely used in healthcare organizations all around the world, which is supposed having the potential to improve the efficiency in outpatient clinics. But the results about the function of EMR were controversial. We developed a Wizard-based outpatient EMR(WEMR) system dedicated to oral and maxillofacial surgery outpatient. Objective: To compare the efficiency of the Wizard-based outpatient EMR(WEMR) and the traditional keyboard character input outpatient EMR(TEMR), which was commonly used in oral and maxillofacial surgery outpatient. Methods: A well trained nurse, who was diagnosed with impacted lower third molar, acted as a standardized patient. 7 attending doctors and 21 interns were randomly allocated into two groups for EMR writing, one group writing medical records with TEMR, and the other with WEMR. And after 3 months of washout period, the writing tools were exchanged. A medical record scoring scale was produced for this standardized patient by three specialists. The documentary time and medical record quality scores of TEMR and WEMR were compared and analyzed. Results: The results showed that the documentary time decreased while the record quality score increased in WEMR group compared with TEMR group, and there were statistically difference between the two groups. At the same time, in the terms of record quality score comparison, the increase in interns group appeared to be greater than attending doctors group after using WEMR. Conclusions: The WEMR system can significantly reduce the documentary time and improve quality of medical records in outpatient of oral and maxillofacial surgery department. At the same time, the WEMR system can help the interns to master medical record writing skills.
机译：背景：电子病历（EMR）已在世界各地的医疗机构中广泛使用，这被认为具有提高门诊效率的潜力。但是有关EMR功能的结果存在争议。我们开发了基于向导的门诊EMR（WEMR）系统，专门用于口腔颌面外科门诊。目的：比较基于向导的门诊EMR（WEMR）和传统的键盘字符输入门诊EMR（TEMR）的效率，后者通常用于口腔颌面外科门诊。方法：一名受过良好训练的护士被诊断为下颌第三磨牙受累，为标准患者。将7名主治医生和21名实习生随机分为两组进行EMR撰写，一组由TEMR撰写病历，另一组由WEMR撰写。经过3个月的淘汰期后，更换了书写工具。由三位专家为该标准化患者制作了病历得分量表。比较和分析了TEMR和WEMR的记录时间和病历质量得分。结果：结果表明，与TEMR组相比，WEMR组的记录时间减少而记录质量得分增加，并且两组之间有统计学差异。同时，就记录质量得分比较而言，使用WEMR后，实习生组的增加似乎大于主治医生组。结论：WEMR系统可以显着减少口腔颌面外科门诊的记录时间并提高病历质量。同时，WEMR系统可以帮助实习生掌握病历撰写技能。

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