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首页> 美国卫生研究院文献>Journal of the American Medical Informatics Association : JAMIA >Handling anticipated exceptions in clinical care: investigating clinician use of ‘exit strategies’ in an electronic health records system
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Handling anticipated exceptions in clinical care: investigating clinician use of ‘exit strategies’ in an electronic health records system

机译：处理临床护理中的预期例外情况：调查临床医生在电子健康记录系统中使用退出策略的情况

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摘要

Unpredictable yet frequently occurring exception situations pervade clinical care. Handling them properly often requires aberrant actions temporarily departing from normal practice. In this study, the authors investigated several exception-handling procedures provided in an electronic health records system for facilitating clinical documentation, which the authors refer to as ‘data entry exit strategies.’ Through a longitudinal analysis of computer-recorded usage data, the authors found that (1) utilization of the exit strategies was not affected by postimplementation system maturity or patient visit volume, suggesting clinicians' needs to ‘exit’ unwanted situations are persistent; and (2) clinician type and gender are strong predictors of exit-strategy usage. Drilldown analyses further revealed that the exit strategies were judiciously used and enabled actions that would be otherwise difficult or impossible. However, many data entries recorded via them could have been ‘properly’ documented, yet were not, and a considerable proportion containing temporary or incomplete information was never subsequently amended. These findings may have significant implications for the design of safer and more user-friendly point-of-care information systems for healthcare.
机译：不可预测但经常发生的异常情况遍布临床护理。正确处理它们通常需要暂时偏离正常实践的异常行为。在这项研究中，作者调查了电子病历系统中提供的几种有助于临床记录的异常处理程序，这些程序被称为“数据输入退出策略”。通过对计算机记录的使用数据进行纵向分析，作者发现（1）退出策略的使用不受实施后系统成熟度或患者就诊量的影响，这表明临床医生对“退出”不良情况的需求持续存在； （2）临床医生的类型和性别是退出策略使用的有力预测指标。深入分析进一步显示，明智地使用了退出策略，并采取了原本就很难或不可能的行动。但是，通过它们记录的许多数据条目本可以“适当地”记录下来，但没有，而且随后包含有暂时或不完整信息的相当一部分也从未得到修改。这些发现可能对设计更安全，更友好的医疗点信息系统具有重要意义。

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