Applied Clinical Informatics, Inhaltsverzeichnis Appl Clin Inform 2012; 03(02): 175-185DOI: 10.4338/ACI-2012-02-CR-0003 Case Report Schattauer GmbH Rapid Implementation of Inpatient Electronic Physician Documentation at an Academic Hospital Authors Institutsangaben J.S. Hahn 1 Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA 2 Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA 3 Information Services, Lucile Packard Children’s Hospital, Palo Alto, CA, USA J.A. Bernstein 2 Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA R.B. McKenzie 2 Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA B.J. King 3 Information Services, Lucile Packard Children’s Hospital, Palo Alto, CA, USA C.A. Longhurst 2 Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA 3 Information Services, Lucile Packard Children’s Hospital, Palo Alto, CA, USA Artikel empfehlen Abstract Volltext als PDF herunterladen(opens in new window) Keywords KeywordsElectronic health records - information storage and retrieval - physician’s practice patterns - software design - time factors - user-computer interface - documentation Referenzen References 1 Ash JS, Bates DW. Factors and forces affecting EHR system adoption: report of a 2004 ACMI discussion. J Am Med Inform Assoc 2005; 12 (01) 8-12. 2 Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress report on electronic health records in U. S. hospitals. Health Aff (Millwood) 2010; 29 (010) 1951-1957. 3 Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff (Millwood) 2011; 30 (03) 464-471. 4 Longhurst CA, Parast L, Sandborg CI, Widen E, Sullivan J, Hahn JS. et al. Decrease in hospital-wide mortality rate after implementation of a commercially sold computerized physician order entry system. Pediatrics 2010; 126 (01) 14-21. 5 Payne TH, tenBroek AE, Fletcher GS, Labuguen MC. Transition from paper to electronic inpatient physician notes. J Am Med Inform Assoc 2010; 17 (01) 108-111. 6 Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc 2004; 11 (02) 104-112. 7 Embi PJ, Yackel TR, Logan JR, Bowen JL, Cooney TG, Gorman PN. Impacts of computerized physician documentation in a teaching hospital: perceptions of faculty and resident physicians. J Am Med Inform Assoc 2004; 11 (04) 300-309. 8 Rosenbloom ST, Denny JC, Xu H, Lorenzi N, Stead WW, Johnson KB. Data from clinical notes: a perspective on the tension between structure and flexible documentation. J Am Med Inform Assoc 2011; 18 (02) 181-186. 9 EMR Adoption Model.. HIMSS Analytics;. 2012 [cited 2012 January 20]; Available from:www.himssana lytics.org/hc_providers/emr_adoption.asp. 10 McCoy MJ, Diamond AM, Strunk AL. Special requirements of electronic medical record systems in obstetrics and gynecology. Obstet Gynecol 2010; 116 (01) 140-143. 11 Rosenbloom ST, Crow AN, Blackford JU, Johnson KB. Cognitive factors influencing perceptions of clinical documentation tools. J Biomed Inform 2007; 40 (02) 106-113. 12 O’Donnell HC, Kaushal R, Barron Y, Callahan MA, Adelman RD, Siegler EL. Physicians’ attitudes towards copy and pasting in electronic note writing. J Gen Intern Med 2009; 24 (01) 63-68. 13 Hirschtick RE. A piece of my mind. Copy-and-paste. JAMA 2006; 295 (020) 2335-2336. 14 Wrenn JO, Stein DM, Bakken S, Stetson PD. Quantifying clinical narrative redundancy in an electronic health record. J Am Med Inform Assoc 2010; 17 (01) 49-53. 15 Bernstam EV, Hersh WR, Sim I, Eichmann D, Silverstein JC, Smith JW. et al. Unintended consequences of health information technology: a need for biomedical informatics. J Biomed Inform 2010; 43 (05) 828-830. 16 Payne TH, Kalus R, Zehner J. Evolution and use of a note classification scheme in an electronic medical record. AMIA Annu Symp Proc 2005: 599-603. 17 Rosenbloom ST, Stead WW, Denny JC, Giuse D, Lorenzi NM, Brown SH. et al. Generating Clinical Notes for Electronic Health Record Systems. Appl Clin Inform 2010; 1 (03) 232-243. 18 Hartzband P, Groopman J. Off the record –avoiding the pitfalls of going electronic. N Engl J Med 2008; 358 (016) 1656-1658. 19 Feblowitz JC, Wright A, Singh H, Samal L, Sittig DF. Summarization of clinical information: a conceptual model. J Biomed Inform 2011; 44 (04) 688-699. 20 Weed LL. Medical records that guide and teach. N Engl J Med 1968; 278 (011) 593-600.