出版社：Utrecht University, Maastricht University, Groningen University
摘要：Relevance : An electronic health record (EHR) is an acknowledged cornerstone of the ´eHealth Ireland Strategy´ (2013), bringing to the fore improved health service efficiencies and information-sharing through the use of technology-enabled healthcare delivery. To improve quality of care, an EHR is essential to eliminate fragmented information, facilitate sharing of clinical records across multidisciplinary teams and locations and support collaboration and effective decision-making. St. James's Hospital is the largest public teaching hospital in Ireland and is leading the way in delivering an EHR across the organisation. Purpose : To develop and implement electronic patient recording across inpatient and outpatient physiotherapy services in St. James's Hospital. Approach/Evaluation : A team including clinicians, information technology (IT) project co-ordinator, physiotherapy management and administration staff came together to design, develop and implement a secure electronic patient record to support clinical care of physiotherapy service-users. Initially, local workflows from receipt of referral to discharge were mapped out. A consultation process was undertaken across specialties with senior physiotherapists and clinical tutors to best establish documentation requirements. Two clinical leads consulted with the project co-ordinator on form design and user-friendliness. Form-building and new workflow development was undertaken by the IT project co-ordinator, with frequent team collaboration. Physiotherapy management oversaw the budget and were consulted on hardware choices and operational issues. Both clinical leads piloted the software on various hardware options, to best determine clinical suitability. Outcomes : To date, successful implementation of electronic recording has been achieved across 70% of physiotherapy services. Enabling the outpatient phase to go live in August 2015, nineteen laptops – the device of choice by outpatient clinicians - were purchased. In the interim, the inpatient phase of the project has been proceeding. Acute medicine, stroke, multiple sclerosis, orthopaedics, oncology, haematology, haemophilia and care of the elderly have completely transitioned to electronic recording, along with critical care and high-dependency inpatient areas. With established workflows and electronic forms built, successful completion is imminent by the second quarter of 2016, with hardware funding approved. Discussion and conclusions : In 2016, it is anticipated 95,000 inpatient and outpatient physiotherapy contacts will be recorded electronically by 56 clinical staff. Electronic records save waste of resources involved in gathering information and investigation results across various media. Including end-users in workflow analysis and paperless system development can be a powerful catalyst in practice change, as conveyed throughout this project. Devoting adequate resources to hardware testing and training also minimises clinician anxiety and resistance to change. Consideration must be given to staff training, induction, patient confidentiality, governance and device security/maintenance when drawing up policies pertaining to electronic patient records. Nursing and medical workstreams are underway to bring a cohesive EHR to fruition in St. James´s Hospital. This project has shown that local expertise and team working are critical success factors in designing and implementing a user-friendly electronic patient record. Documentation audit and service-user satisfaction will be explored in the future. Impact and Implications : Integrated sharing of communication across disciplines throughout the patient journey is enabled with robust secure electronic recording. There are also significant implications for quality, safety and cost.
