急診外傷病歷電子化之建置與設計

The design and implementation of electronic emergency medical record of trauma

本研究的目的是將急診外傷病歷資料進行結構化和電子化，以提高緊急醫療效率並減輕醫師的臨床病歷記錄負擔。研究團隊由資訊室和外傷及重症外科合作，分析所需欄位並討論技術實施方案，開發了急診外傷病歷電子化系統。該系統提供了非常貼切的使用者界面，使得急診室醫師可以輕鬆操作並在最短時間內獲得最關鍵的病人資訊。研究成效評估時間為2020年1月至2020年3月。研究結果顯示，在檢傷一級部分，主治醫師紙本病歷平均需耗時3分24秒，而使用第三版電子病歷則減少為2分57秒；非主治醫師平均需耗時6分1秒，使用第三版電子病歷則為4分27秒。平均減少了1分1秒，降幅達到了25.4%。在檢傷三級部分，主治醫師紙本病歷平均需耗時1分28秒，而使用第三版電子病歷則減少為1分10秒；非主治醫師平均需耗時2分3秒，使用第三版電子病歷則為1分30秒。平均減少了40秒，降幅達到了25.6%。本研究透過密切溝通和修正加速雙方度過磨合期，確實利用資訊技術來解決臨床實務的痛點，對於紙本病歷轉換成電子化的過程中所遭遇到的臨床作業流程習慣改變上的衝突，也提出了解決方案。此外，該研究還指出後端資料的應用也有很大的發展空間。

The study aims to structure and digitize emergency department (ED) trauma medical records to improve the efficiency of emergency medical care and reduce the clinical record-keeping burden on physicians. The research team consisted of the Information Department and the Division of Trauma and Surgical Critical Care, who deconstructed the required fields and discussed the technical implementation to develop an electronic medical record (EMR) system for ED trauma patients. The system provides a very user-friendly interface that enables ED physicians to easily operate and obtain the most critical patient information in the shortest time possible.
The effectiveness of this study was evaluated from January to March 2020. The results showed that for triage level 1, the average time for attending physicians to document the medical record on paper was 3 minutes and 24 seconds, which decreased to 2 minutes and 57 seconds with the third version of the EMR system. For non-attending physicians, the average time was 6 minutes and 1 second, which decreased to 4 minutes and 27 seconds with the third version of the EMR system. On average, the time was reduced by 1 minute and 1 second, a decrease of 25.4%. For triage level 3, the average time for attending physicians to document the medical record on paper was 1 minute and 28 seconds, which decreased to 1 minute and 10 seconds with the third version of the EMR system. For non-attending physicians, the average time was 2 minutes and 3 seconds, which decreased to 1 minute and 30 seconds with the third version of the EMR system. On average, the time was reduced by 40 seconds, a decrease of 25.6%.
Through close communication and modification, this study effectively utilized information technology to solve the pain points in clinical practice and provided solutions for conflicts encountered in the transition from paper medical records to electronic records. In addition, the study also indicated that there is significant room for the application of backend data.