국내 전자간호기록 개발 및 실무적용 현황 조사
The Adoptions and Use of Electronic Nursing Records in Korean Hospitals: Findings of a Nationwide Survey
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Purpose: To provide clear estimates of the adoption and use of electronic nursing records (ENRs) with standard terminology in Korea and identification of the scope and use as well as perceived or potential benefits of ENRs. Methods: A survey was done of 733 hospitals at three levels: tertiary advanced hospitals, general hospitals, and community hospitals. After performing a literature review a modified version of an existing survey tool was used for 2 months in 2012. The collected information related to EHR functionality and coverage of nursing documentation and nursing process, application of standard terminology, and perceived satisfaction and benefits of ENRs. Results: The response rate was 39.4% (289/733), and 202 hospitals (70.1%, 95% CI64.8~75.5%) of the respondents had ENR systems (82.5% of tertiary hospitals, 66.7% of general hospitals, and 70.1% of community hospitals). Out of these hospitals less than 10% had ENRs fully covering nursing documentation. The adoption rate of standard terminology was 55%, and hospital satisfaction with ENRs was 70%. But personalized care was identified as needing improvement in ENRs. Conclusion: The ENR adoption rate was high but there are many potential opportunities for improving ENR systems in terms of the data standardization and personalized care.
Abstract
Purpose: To provide clear estimates of the adoption and use of electronic nursing records (ENRs) with standard terminology in Korea and identification of the scope and use as well as perceived or potential benefits of ENRs. Methods: A survey was done of 733 hospitals at three levels: tertiary advanced hospitals, general hospitals, and community hospitals. After performing a literature review a modified version of an existing survey tool was used for 2 months in 2012. The collected information related to EHR functionality and coverage of nursing documentation and nursing process, application of standard terminology, and perceived satisfaction and benefits of ENRs. Results: The response rate was 39.4% (289/733), and 202 hospitals (70.1%, 95% CI64.8~75.5%) of the respondents had ENR systems (82.5% of tertiary hospitals, 66.7% of general hospitals, and 70.1% of community hospitals). Out of these hospitals less than 10% had ENRs fully covering nursing documentation. The adoption rate of standard terminology was 55%, and hospital satisfaction with ENRs was 70%. But personalized care was identified as needing improvement in ENRs. Conclusion: The ENR adoption rate was high but there are many potential opportunities for improving ENR systems in terms of the data standardization and personalized care.
참고문헌 (31)
- "Nursing Informtics Working Group" (2012)[URL]
- American Nurses Association., "Nursing informatics : Scope and standards of practice" (2008), American Nurses Association
- Barey, E. B., "The electronic health record and clinical informatics, In Nursing informatics and the foundation of knowledge", pp.219~249 (2009), Jones and Bartlett Learning
- Blumenthal, D., "The"Meaningful Use"regulation for electronic health records", New England Journal of Medicine, 363(6), pp.501~504 (2010)[DOI]
- "ABMS Announces certification in two new physician subspecialties: Clinical informatics and brain injury medicine. American Board of Medical Specialties" (2011)[URL]
- Development of clinical decision support systems, "Center for Interoperable Electronic Health Record (EHR)", Center for Interoperable Electronic Health Record (EHR), ~, pp.Rep. No. 7 (2010)
- Chaudhry, B., "Systematic review : Impact of health information technology on quality, efficiency, and costs of medical care", Annals of Internal Medicine, 144(10), pp.742~752 (2006)
- Cho, I., "Evaluation of the expressiveness of an ICNP-based nursing data dictionary in a computerized nursing record system", Journal of the American Medical Infomatics Association, 13(4), pp.456~464 (2006)
- Cho, I., "Formative evaluation of standard terminology-based electronic nursing record system in clinical setting", Journal of Korean Society of Medical Informatics, 9(4), pp.413~421 (2003)
- DesRoches, C. M., "Electronic health records in ambulatory care", The New England Journal of Medicine, 359(17), pp.1848~1849 (2008)
- DesRoches, C. M., "Electronic health records in ambulatory care - A national survey of physicians", The New England Journal of Medicine, 359(1), pp.50~60 (2008)[DOI]
- Dykes, P. C., "Adequacy of evolving national standardized terminologies for interdisciplinary coded concepts in an automated clinical pathway", Journal of Biomedical Informatics, 36(4-5), pp.313~325 (2003)[DOI]
- Dykes, P. C., "The adequacy of ICNP version 1. 0 as a representational model for electronic nursing assessment documentation", Journal of the American Medical Informatics Association, 16(2), pp.238~246 (2009)[DOI]
- Fowler, F. J. Jr., "Survey research methods" (2009), Sage Publications
- Hardiker, N. R., "Formal nursing terminology systems : A means to an end", Journal of Biomedical Informatics, 35(5-6), pp.298~305 (2002)[DOI]
- HIMSS dictionary of healthcare information technology terms, acronyms of organizations, "Healthcare Information", Healthcare Information and Management Systems Society (HIMSS), ~ (2006)
- Henry, S. B., "Nursing classification systems : Necessary but not sufficient for representing ''what nurses do'' for inclusion in computer-based patient record systems", Journal of the American Medical Informatics Association, 4(3), pp.222~232 (1997)
- Hovenga, E., "Nursing constraint models for electronic health records : A vision for domain knowledge governance", International Journal of Medical Informatics, 74(11-12), pp.886~898 (2005)[DOI]
- Hübner, U., "IT adoption of clinical information systems in Austrian and German hospitals: Results of a comparative survey with a focus on nursing", BMC Medical Informatics and Decision Making, 10 (2010)[DOI]
- Key capabilities of an electronic health record system : Letter report, "Institute of Medicine", ~ (2003)
- 지재훈, "병원의 외부환경 및 조직특성이 정보화 수준에 미치는 영향", 보건의료산업학회지, 5(1), pp.133~145 (2011), 보건의료산업학회
- Information strategic planning for communicating patients electronic information between medical institutions in Korea, "Korea Health Industry Development Institute", Korea Health Industry Development Institute, ~ (2000)
- "Assessing adoption of effective health information technology questionnaire" (2005)[URL]
- 2007 Assessment for level of industry information system, "National Information Society Agency", National Information Society Agency, ~, pp.NIA III Rep. 07007 (2007)
- Park, R. W., "Computerized physician order entry and electronic medical record systems in Korean teaching and general hospitals : Results of a 2004 survey", Journal of the American Medical Informatics Association, 12(6), pp.642~647 (2005)
- Porcella, A., "Narrative notes in a nursing information system (NIS)", Journal of the American Medical Informatics Association, pp.538~542 (2001)
- Singh, R., "The adoption and use of health information technology in rural areas: Results of a national survey", The Journal of Rural Health, 28(1), pp.16~27 (2012)[DOI]
- Sittig, D. F., "A survey of U.S.A. acute care hospitals' computer-based provider order entry system infusion levels", Studies in Health Technology and Informatics, 129(Pt 1), pp.252~256 (2007)
- Stevenson, J. E., "Nurses' experience of using electronic patient records in everyday practice in acute", inpatient ward settings : A literature review, 2010, pp.16(1), 63~72
- Turkel, M. C., "Instead of reconceptualizing the nursing process let's re-name it", Nursing Science Quarterly, 25(2), pp.194~198 (2012)[DOI]
- Yoon, D., "Adoption of electronic health records in Korean tertiary teaching and general hospitals", International Journal of Medical Informatics, 81(3), pp.196~203 (2012)[DOI]