1、 1 外文翻译 原文 Physicians Use Of Electronic Medical Records: Barriers And Solutions Material Source: Health Affairs Author: Robert H. Miller and Ida Sim Abstract The electronic medical record (EMR) is an enabling technology that allows physician practices to pursue more powerful quality improvement prog
2、rams than is possible with paper-based records. However, achieving quality improvement through EMR use is neither low-cost nor easy. Based on a qualitative study of physician practices that had implemented an EMR, we found that quality improvement depends heavily on physicians use of the EMR and not
3、 paper for most of their daily tasks. We identified key barriers to physicians use of EMRs. We then suggest policy interventions to overcome these barriers, including providing work/practice support systems, improving electronic clinical data exchange, and providing financial rewards for quality imp
4、rovement. In this paper we present key results of our qualitative study on the opportunities and barriers that ambulatory physician practices encounter when using EMRs for quality improvement. Based on insights from this study, we then suggest policy interventions that can promote opportunities for
5、and lower barriers to using EMRs for quality improvement. Methods We conducted nearly ninety interviews between mid-2000 and the end of 2002 with EMR managers and physician champions in thirty physician organizations that had implemented an EMR. The organizations were purposefully selected for their
6、 diversity in sizes, EMR used, duration of EMR use, affiliations, and extent of capitated payment. Studied organizations included nine large medical groups of more than seventy physicians each, eighteen solo/small-group practices of ten or fewer physicians, and three medium-size groups. Most of the
7、small groups were primary care only, while eight of the large groups were multispeciality; we focused primarily on EMR use by primary care physicians. Some data were obtained from the same organization at several points in time. 2 Study Results Viewing. All practices used EMR viewing capabilities, w
8、hich improve chart availability, data organization, and legibility. Quality benefits depended on the amount of viewable clinical data. The amount of initially viewable data depended on efforts to type in existing paper-based medical record data and to electronically import data from lab, billing, an
9、d other systems. As patient data accumulated over time, financial savings accrued from less staff time spent finding, pulling, and filing charts and less physician time spent locating information. Documentation and care management. We identified a consistent relationship between greater electronic d
10、ocumentation by physicians and greater quality improvement and financial benefits. Just as computerized physician order entry (CPOE) appears central to generating benefits in hospital settings, physician electronic documentation appears central to generating benefits in ambulatory care settings. Ord
11、ering. Basic use of electronic ordering typically consisted of physicians typing in prescription orders, responding to drug interactions and drug allergy alerts, and printing out prescriptions. All but three practices we studied used electronic prescribing. In large practices, basic ordering often a
12、lso included electronic ordering of referrals and laboratory and radiology tests. More advanced ordering capabilities included additional decision support, electronic transmission of orders to pharmacies and laboratories, and better tracking of test-order status and test results, all of which can im
13、prove quality and decrease errors. Messaging. Basic use of electronic messaging among providers improved the availability, timeliness, and accuracy of messages and increased completeness of documentation, thus potentially reducing “dropped balls“ and safety problems. Much less common was advanced me
14、ssaging, which included messaging with outside providers (to improve care coordination) and with patients (to improve patient satisfaction and, potentially, patient self-care and compliance). Analysis and reporting. Few practices initially used physician performance monitoring and feedback capabilit
15、ies to improve quality and efficiency. Over time, some practices especially larger ones used reporting capabilities more widely: For example, some practices generated reports to physicians on diabetic patients with hemoglobin A1C levels greater than 8 percent and on the percentage of a physicians pa
16、tients having such levels. 3 Patient-directed functionality. Most practices had limited or nonexistent practice Web sites for patients. A few large-practice Web sites enabled patients to schedule visits, send secure e-mail messages to providers, receive e-mail reminders, order medications, access th
17、eir charts, and obtain more individualized educational patient care information all of which have the potential to improve quality.6 Billing. Increased integration between billing and EMR software, combined with electronic documentation, can yield financial benefits through more complete capture of
18、services provided, more defensible Medicare coding at higher coding levels, and reductions in data-entry staff. Barriers to EMR use. Key surface barriers to EMR use that emerged as persistent themes from our interview data included high initial financial costs, slow and uncertain financial payoffs,
19、and high initial physician time costs. Underlying barriers included difficulties with technology, complementary changes and support, electronic data exchange, financial incentives, and physicians attitudes. These barriers were most acute for physicians in solo/small-group practice, a mode in which a
20、 substantial majority of U.S. physicians practice.7 High initial cost and uncertain financial benefits. The high up-front financial costs of implementing EMRs is a primary barrier to their adoption. This barrier is compounded by uncertainty over the size of any financial benefits that may accrue ove
21、r time. In most practices we studied, up-front costs ranged from $16,000 to $36,000 per physician. Some practices incurred additional costs (in the form of decreased revenue) from seeing fewer patients during the EMR transition period.8 High initial physician time costs. Interviewees reported that m
22、ost physicians using EMRs spent more time per patient for a period of months or even years after EMR implementation. The increased time costs resulted in longer workdays or fewer patients seen, or both, during that initial period. Technology. Most respondents or their colleagues considered even high
23、ly regarded, industry-leading EMRs to be challenging to use because of the multiplicity of screens, options, and navigational aids. Problems with EMR usability especially for documenting progress notes caused physicians to spend extra work time to learn effective ways to use the EMR. These substanti
24、al initial time costs are an important barrier to obtaining benefits, as greater burdens on physicians time decrease their use of EMRs, which lowers the potential for achieving quality improvement. 4 Difficult complementary changes and inadequate support. EMR hardware and software cannot simply be u
25、sed “out of the box.“ Instead, physician practices must carry out many complex, costly, and time-consuming activities to “complement“ the EMR product. Across industries, such complementary changes have been found to be critical for generating benefits from new technology.10 Inadequate electronic dat
26、a exchange. Another barrier to EMR use was the lack of adequate electronic data exchange between the EMR and other clinical data systems (such as lab, radiology, and referral systems). Having parallel electronic and paper-based systems forced physicians to switch between systems, thereby slowing wor
27、kflow, requiring more time to manually enter data from external systems, and increasing physicians resistance to EMR use. Furthermore, with fewer data in the EMR, there was less opportunity for intervening electronically to improve quality, and reduced ability to perform internal analyses or to repo
28、rt performance externally for quality report cards or performance incentive programs.12 Lack of incentives. EMR use could be increased through financial rewards for quality improvement and for public reporting of multiple measures of quality performance. Yet few interviewees reported any financial i
29、ncentives for quality, and none reported public reporting of their quality performance compared with that of other physician practices. The lone practice that operated under substantial financial incentives for quality improvement intensified its use of the EMR and reaped sizable financial rewards.
30、Physicians attitudes. Most interviewees were EMR champions who had positive, “can-do“ attitudes toward solving EMR-related problems and who were vital to getting other physicians to use EMRs. These physicians innovation “early adopters“ were willing to bear initial financial and time costs to genera
31、te benefits.13 In contrast, nonchampion physicians tended to be less positive toward EMRs and more easily discouraged by usability problems. Without exhortation and support from physician champions, these physicians tended to remain as lower-level EMR users. As a result, practices without physician
32、EMR champions may flounder in their efforts to generate quality or financial benefits from EMRs. Potential Solutions We believe that public and private policy interventions can effectively counter several of the barriers we identified to ambulatory EMR adoption and use for quality improvement. Indee
33、d, such interventions are essential for solo/small-group practices that lack the organizational resources of large groups. Each policy intervention 5 suggested below either decreases EMR time costs to physicians or increases financial benefits, thereby increasing the attractiveness of EMR use to phy
34、sicians. Communitywide data exchange. Ubiquitous, secure electronic exchange of clinical data among providers would help lessen the disruption from parallel electronic and paper-based medical record systems, thereby decreasing physician time costs and increasing financial benefits. Performance incen
35、tives and mandates. Financial payback to practices for achieving quality improvement or mandates for IT use would also increase the adoption and use of EMRs for quality improvement. In a highly positive development, a small but growing number of purchasers, health plans, and employers are initiating
36、 quality-based reimbursement programs, rewarding practices for publishing performance reports, mandating specific quality improvement actions or use of specific IT applications, and even rewarding consumers for choosing higher-quality providers on the basis of these performance reports.18 Support fo
37、r complementary changes. Physician practices, especially solo/small-group practices, require support to carry out the time-consuming workflow and other complementary changes needed to generate financial and quality benefits from “out-of-the-box“ EMRs. Both established EMR vendors and current ASP fir
38、ms, however, tend to provide only technical support for their products. From a policy perspective, providing support for complementary changes is crucial but challenging and will require much experimentation. We suggest that funding agencies support the demonstration and evaluation of various models
39、 for providing comprehensive EMR support services to solo/small-group practices to catalyze the development of such services in the market. In addition, funders should support comparative evaluations of existing support services, to intensify competitive pressure for their development. The EMR is an
40、 enabling technology for physician practices to pursue quality improvement in potentially powerful ways. Our research finds, however, that systematic quality improvement using EMRs is neither low-cost nor easy. There is no simple solution to accelerating EMR adoption and use for quality improvement.
41、 Given the multifaceted nature of the barriers, a range of policy interventions is needed to spur successful EMR-driven quality improvement. These policy interventions center on improving data exchange among health care entities, providing financial rewards for quality improvement, and providing wor
42、k/practice 6 support. This package of policy interventions, in combination with ongoing trends, should hasten adoption of EMRs and their use for quality improvement in ambulatory care. 译文 医生在应用电子病历中的障碍和解决方法 资料来源：健康时事 作者：罗伯特 .H.米勒 艾达 .西姆 电子病历 (EMR)是一项法律许可的技术，它使医生能尝试着运用比纸质记录更有力的电子病历程序的系统。然而，通过运用电子病历而获
43、得品质的提升既不廉价也不简单。基于已应用电子病历系统的医生的实践中的定性研究，我们可以看到，品质的提升很大程度上取决于医生在日常工作中对电子病历而不是纸张的应用。我们发现 了医生在应用电子病历过程中的一些障碍，随后，我们提出了一些 措施 去克服这些障碍，包括提供工作或实践支持系统、改善电子临床数据交流以及提供对品质提升的财政奖励。 本文介绍了我们对医生在应用电子病历以提升品质的实践中所遇到的机会和障碍的定性研究的重要结论。基于对这个研究的深入了解，我们提出了可以在应用电子病历以提升品质的过程中增加机会及降低障碍的调节策略。 方法 在 2000 年中期到 2002 年末期间，我们分别与 30 家
44、运用电子病历的医疗组织的电子病历经理及一流医生进行了将近 90 个会谈。我们有目的的因其在规模、电子病历 应用情况、应用电子病历的时间、从属关系及人均支付范围的不同而选择了这些组织。接受调查的组织包括 9 个各拥有超过 70 名医生的大规模医疗团体， 18 个由 10 名或更少的医生组成的独立的或小规模的团体实践活动及 3 个中等规模的团体。多数小团体都只有初级医疗，而大规模团体中的 8 个是多专科诊所。我们主要关注的是初级医疗医生们对电子病历的使用。许多数据来自于同一组织在不同时间点的情况。 研究结论 观察 所有使用电子病历的实践活动都在观测一些性能， 这些性能可以提高图表的有效性、数据的组
45、织及易读性。品质利益取决于可见的医疗数据的总数 ，初期的可见数据的总数取决于努力把现有纸质医疗记录进行分类及对从实验、广告和其他系统中获得的数据进行电子输入。正如病患的数据随时间而积累，财政的积累由职工在寻找、获得及整理图表缩短时间及医生在找到信息时缩短时间中产生。 7 文献资料及护理管理 ， 我们发现了来自医生的更多的文献资料和更大的品质提升及财政利润之间的一个协调的关系，正如计算机化医嘱输入（ CPOE）似乎以在医疗设施中产生利润为中心，而医生电子文献资料似乎以在非卧床护理设施中获取利益为中心。尽管大多数临床医师保留电子问题及变态反应性清单，医生们对于他们怎样 为进行记录提供文献是不同的，
46、或者他们将自己的进程记录 在无结构的盒子中分类。更多先进的使用者将数据输入包括物理测试及文献提示的模板（电子形式的）中。 定序 电子定序的基本应用通常由医生们对处方指令的输入、对药物的相互作用和变态性反应提醒的回应以及打印出药方组成。所有我们研究的实践活动中除了 3 个都使用了电子处方，在大型的实践活动中，基础定序通常也包括参考的和实验室的电子定序以及放射学测试。更多先进的定序性能包括附加的决定支持、对药店及实验室的命令的电子传输，以及对测试要求的状态及测试结果的更好的追踪，所有的这些都 能提升品质并减少错误。 信息传输， 供应者对电子信息传输的基本应用提高了信息的可用性、及时性和准确性，并且
47、提高了文献资料的完整性，这样潜在的减少了 “ 下坠球 ” 及安全问题。更少的共性是先进的信息传输，包括外部供应者提供的信息传输（以增加护理协作）及病患提供的信息传输（以提高病患的满意度，并可能的提高病患的自我照顾能力及遵从医嘱）。 发送安全的电子邮件、接收电子邮件提示、询问药物、查看他们的图表以及接受更多的个性化的病患护理信息教育，而所有的这些都有提升品质的潜力。 记账 通过更多的获得提供的服务、更多的在更高编码水 平上的可防御的老年保健医疗制度编码以及数据输入职工的再教育，更多与电子文献资料 结合的记账和电子病历软件的整体可以产生财政利润。 分析和报告 少数实践活动初期使用医生工作监测和反馈
48、性能以提升品质及效率，随着时间的推移，一些实践活动，特别是那些大规模的，更大范围的使用报告性能。例如，为医生提供关于多于 8%的血红蛋白 A1C 级的糖尿病患者的报告以及医生的处于这个级别的病患的百分比。 病患主导功能 ， 大多数实践活动为病患提供有限的或者是不提供操作网站，少数一些大型的操作网站使病患能够进行预约、给提供方 电子病历应用的障碍 ， 主要电子病历应用的表面障碍从我们的采访数据中作为持久的主题而出现，这些数据包括巨额初期财政支出、缓慢及不稳定的财政盈利以及过高的初期医生时间消耗。潜在的障碍包括技术难题、其他的变化和支持、电子数据交流、财政奖励以及医生的态度。这些障碍对于独立的或小
49、规模的实践团体的医生来说是最严重的，而美国大多数的医生操作都采用的这种模式。 8 高额初期投资和不确定的财政利润 使用电子病历的高额初期财政支出是他们应用电子病历的基本障碍，这个障碍可以通过不确定性来解决，而这个不确定性就是随时间而产生的财政利润的多少。在多数我们研究的实践活动中，每位医生的初期花费从 16， 000 美元到 36， 000 美元不等，还有一些实践活动从医生在电子病历过度时期会接诊更少的病患这个事实中产生额外的花费。 较多的初期医生时间消耗 接受采访的人表示，大多数使用电子病历的医生在电子病历过度后的几个月甚至几年里，会在每个病患身上花费更多的时间，这个逐渐增加的时间消耗在最初的那段时间里导致了更长的工作时间或者接 诊更少的病患或者两者都有。 技术 ， 大多数接受采访的人或者他们的同事都因屏幕、选项的多样性及导航设备而尝试着使用工业化的电子病历，而电子病历可用性的难题，特别是用作记录文献，迫使医生们为学习怎样有效的使用电子病历而付出额外的工作时间。这些大量的初期时间消耗是获取利润的主要障碍，它作为医生时间的
