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首页> 外文期刊>JMIR Medical Informatics >Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study
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Implementing Structured Clinical Templates at a Single Tertiary Hospital: Survey Study

机译：在单一高等院医院实施结构化临床模板：调查研究

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Background Electronic health record (EHR) systems have been widely adopted in hospitals. However, since current EHRs mainly focus on lowering the number of paper documents used, they have suffered from poor search function and reusability capabilities. To overcome these drawbacks, structured clinical templates have been proposed; however, they are not widely used owing to the inconvenience of data entry. Objective This study aims to verify the usability of structured templates by comparing data entry times. Methods A Korean tertiary hospital has implemented structured clinical templates with the modeling of clinical contents for the last 6 years. As a result, 1238 clinical content models (ie, body measurements, vital signs, and allergies) have been developed and 492 models for 13 clinical templates, including pathology reports, were applied to EHRs for clinical practice. Then, to verify the usability of the structured templates, data entry times from free-texts and four structured pathology report templates were compared using 4391 entries from structured data entry (SDE) log data and 4265 entries from free-text log data. In addition, a paper-based survey and a focus group interview were conducted with 23 participants from three different groups, including EHR developers, pathology transcriptionists, and clinical data extraction team members. Results Based on the analysis of time required for data entry, in most cases, beginner users of the structured clinical templates required at most 70.18% more time for data entry. However, as users became accustomed to the templates, they were able to enter data more quickly than via free-text entry: at least 1 minute and 23 seconds (16.8%) up to 5 minutes and 42 seconds (27.6%). Interestingly, well-designed thyroid cancer pathology reports required 14.54% less data entry time from the beginning of the SDE implementation. In the interviews and survey, we confirmed that most of the interviewees agreed on the need for structured templates. However, they were skeptical about structuring all the items included in the templates. Conclusions The increase in initial elapsed time led users to hold a negative opinion of SDE, despite its benefits. To overcome these obstacles, it is necessary to structure the clinical templates for optimum use. In addition, user experience in terms of ease of data entry must be considered as an essential aspect in the development of structured clinical templates.
机译：背景技术电子健康记录（EHR）系统已广泛采用医院。但是，由于目前的EHR主要关注降低所使用的纸质文档的数量，因此它们遭受了较差的搜索功能和可重用性能力。为了克服这些缺点，已经提出了结构化的临床模板;但是，由于数据输入不便，它们并不广泛使用。目的本研究旨在通过比较数据输入时间来验证结构化模板的可用性。方法采用韩国第三大学医院实施了临床含量的结构化临床模板，临床内容的建模。因此，已经开发了1238种临床含量模型（即，身体测量，生命体征和过敏症），并为临床实践的EHRS应用了492种临床模板，包括病理报告。然后，为了验证结构化模板的可用性，将使用来自结构化数据条目（SDE）日志数据的4391条目和4265条目与自由文本日志数据的4265条目进行比较了从自由文本和四个结构化病理学报告模板的数据输入时间。此外，基于纸张的调查和焦点组访谈是由来自三个不同群体的23名参与者进行，包括EHR开发人员，病理转录员和临床数据提取团队成员。结果根据数据输入所需时间的分析，在大多数情况下，结构化临床模板的初级用户最多需要70.18％的数据输入时间。然而，随着用户习惯于模板的，他们能够比通过自由文本输入更快地进入数据：至少1分钟和23秒（16.8％），最多5分钟和42秒（27.6％）。有趣的是，精心设计的甲状腺癌病理学报告从SDE实施开始时需要14.54％的数据入口时间。在访谈和调查中，我们确认大多数受访者都同意对结构化模板的需求。但是，它们对构建模板中包含的所有项目持怀疑态度。结论尽管有益于，但仍然存在初始经过的时间LED用户对SDE的负面影响。为了克服这些障碍，有必要建立临床模板以获得最佳用途。此外，在数据进入方便方面的用户体验必须被视为结构化临床模板的开发中的重要方面。

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