综合放射肿瘤学网络中基于放射肿瘤学的电子健康记录

A. Colonias, D. Parda, S. Karlovits, R. Fuhrer, M. Trombetta, S. Strickland, Marc Luick, R. Billy, E. Werts
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引用次数: 4

摘要

目的:这个正在进行的项目的目标是在多设施放射肿瘤学网络中开发和集成一个全面的电子健康记录(EHR),以促进更有效的工作流程,并改善整体患者护理和安全性。方法:我们要求EHR在提供可靠的临床健康记录的同时,为放射治疗提供预定义的记录和验证能力。1996年,我们开始整合整个西宾夕法尼亚大学阿勒格尼放射肿瘤学网络的局域网治疗信息系统(LANTIS®)(目前包括9个站点)。到2001年,我们开始修改和扩展评估组件,创建用户定义模板,并在我们的网络中开发了一个全面的电子健康记录。结果:除了获取影像引导治疗的技术记录、验证信息和影像外,我们还根据网络需求设计定制了6个模块,便于信息获取、跟踪和分析,具体如下:1)人口统计/调度;2)收费代码;3)转录/临床文件;4)临床/技术评估;5)医嘱6)质量保证途径。每个模块的开发都是为了让科室内的不同工作人员以有效的方式获取特定的技术/临床数据,其格式便于查询数据以进行结果/统计分析,并促进标准化的质量准则,从而提高工作流程的效率,改善患者的安全和护理。结论:在放射肿瘤学网络中开发一个全面的电子病历是可行的,并且可以定制以提高临床/技术标准,促进结果研究,并改善沟通和同行评审。电子病历改善了患者护理和跨多设施放射肿瘤学系统的网络整合,并显著减少了网络中的纸张流动和存储。
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A Radiation Oncology Based Electronic Health Record in an Integrated Radiation Oncology Network
Purpose: The goal of this ongoing project is to develop and integrate a comprehensive electronic health record (EHR) throughout a multi-facility radiation oncology network to facilitate more efficient workflow and improve overall patient care and safety. Methodology: We required that the EHR provide pre-defined record and verify capability for radiation treatment while still providing a robust clinical health record. In 1996, we began to integrate the Local Area Network Treatment Information System (LANTIS®) across the West Penn Allegheny Radiation Oncology Network (currently including 9 sites). By 2001, we began modifying and expanding the assessment components and creating user-defined templates and have developed a comprehensive electronic health record across our network. Results: In addition to access to the technical record and verify information and imaging obtained for image-guided therapy, we designed and customized 6 modules according to our networks needs to facilitate information acquisition, tracking, and analysis as follows: 1) Demographics/scheduling; 2) Charge codes; 3) Transcription/clinical documents; 4) Clinical/technical assessments; 5) Physician orders 6) Quality assurance pathways. Each module was developed to acquire specific technical/clinical data prospectively in an efficient manner by various staff within the department in a format that facilitates data queries for outcomes/statistical analyses and promotes standardized quality guidelines resulting in a more efficient workflow and improved patient safety and care. Conclusions: Development of a comprehensive EHR across a radiation oncology network is feasible and can be customized to promote clinical/technical standards, facilitate outcomes studies, and improve communication and peer review. The EHR has improved patient care and network integration across a multi-facility radiation oncology system and has markedly reduced the flow and storage of paper across the network.
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