Application of structured electronic medical records for pulmonary nodules in standardized training of resident physicians_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SHI Si’en , YU Xiuyi , FAN Sheng , GENG Guojun ,  JIANG Jie

Department of Thoracic Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, Fujian, P. R. China;

Corresponding?author：

JIANG Jie, Email: jiangjie06@126.com

Keywords：

Standardized training of resident physicians; pulmonary nodules; structured electronic medical records; clinical teaching; case writing

DOI：

10.7507/1007-4848.202101056

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To analyze the value of structured electronic medical records for pulmonary nodules in increasing the ability of outpatient service and hospital management by resident physicians.Methods We included 40 trainees [94 males and 26 females aged 22-31 (26.45±2.81) years] who were trained in the standardized training base for surgical residents in our hospital from January 2018 to January 2021. The trainees were randomly divided into two groups including a structured group using the structured electronic medical record for pulmonary nodule and an unstructured group using unstructured electronic medical record designed by our department. The time of completing hospitalization records and first-time course records, the quality of course records, the accuracy of issuing admission orders, the quality of teaching rounds, and patient’s satisfaction between the two groups were analyzed and compared.Results (1) The average time in the structured group to complete inpatient medical records was significantly shorter than that of the unstructured group (53.61±8.12 min vs. 84.25±16.09 min, P<0.010); the average time in the structured group to complete the first-time course record was shorter than that of the unstructured group (13.20±5.43 min vs. 27.51±8.62 min, P<0.010), and there was a significant statistical difference between the two groups. (2) The overall teaching round quality score of the students in the structured group was significantly higher than that in the unstructured group (84.21±15.61 vs. 70.91±12.28, P<0.010). (3) The score of the medical record writing quality of the structured group was significantly higher than that of the unstructured group (80.25±9.22 vs. 74.22±5.40, P<0.010).Conclusion The structured electronic medical record specific for pulmonary nodules can effectively improve the training efficiency in the standardized training of surgical residents, improve the clinical ability to deal with pulmonary nodules, improve the integrity and accuracy of key clinical data collected by students, and improve doctor-patient relationship.

Citation： SHI Si’en, YU Xiuyi, FAN Sheng, GENG Guojun, JIANG Jie. Application of structured electronic medical records for pulmonary nodules in standardized training of resident physicians. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(6): 703-710. doi: 10.7507/1007-4848.202101056 Copy

1.	Colicchio TK, Cimino JJ, Del Fiol G. Unintended consequences of nationwide electronic health record adoption: Challenges and opportunities in the post-meaningful use era. J Med Internet Res, 2019, 21(6): e13313.
2.	Tierney MJ, Pageler NM, KahanaM, et al. Medical education in the electronic medical record (EMR) era: Benefits, challenges, and future directions. Acad Med, 2013, 88: 748-752.
3.	Stephens MB, Gimbel RW, Pangaro L. Commentary: The RIME/EMR scheme: An educational approach to clinical documentation in electronic medical records. Acad Med, 2011, 86: 11-14.
4.	Yuan CM, Little DJ, Marks ES, et al. Nephrology Education Research and Development Consortium—NERDC. The electronic medical record and nephrology fellowship education in the United States: An opinion survey. Clin J Am Soc Nephrol, 2020, 15(7): 949-956.
5.	Fernando B, Kalra D, Morrison Z, et al. Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: Systematic review. BMJ Qual Saf, 2012, 21(4): 337-346.
6.	Kuo KM, Talley PC, Kuzuya M, et al. Development of a clinical support system for identifying social frailty. Int J Med Inform, 2019, 132: 103979.
7.	Furukawa M, Pollack E. Achieving HIMSS stage 7 designation for EMR adoption. Nurs Manage, 2020, 51(1): 10-12.
8.	Clunie DA, Dennison DK, Cram D, et al. Technical challenges of enterprise imaging: HIMSS-SIIM collaborative white paper. J Digit Imaging, 2016, 29(5): 583-614.
9.	戴潔, 姜格寧. 肺部多發結節的診斷、分期和治療現狀. 中華胸心血管外科雜志, 2020, 36(9): 562-568.
10.	薛寶函, 高學軍. 肺小結節精準定位的現狀及進展. 臨床肺科雜志, 2019, 24(8): 1543-1546.
11.	程良, 江中輝, 高薇, 等. 肺部惡性磨玻璃結節的外科診治現狀. 中華胸心血管外科雜志, 2019, 35(12): 763-768.
12.	陳萬青, 李賀, 孫可欣, 等. 2014 年中國惡性腫瘤發病和死亡分析. 中華腫瘤雜志, 2018, 40(1): 5-13.
13.	金玉晶, 唐威, 黃遙, 等. 基于低劑量 CT 肺癌篩查的肺癌相關危險因素分析. 中華腫瘤雜志, 2020, 42(3): 222-227.
14.	周麗娜, 吳寧, 趙世俊, 等. 基于高分辨率 CT 特征鑒別同時多原發肺腺癌與肺腺癌伴肺內轉移. 中華腫瘤雜志, 2020, 42(6): 449-455.
15.	邸天男, 葛春蕾. 關于住院醫師規范化培訓的現狀與思考. 繼續醫學教育, 2020, 34(3): 12-14.
16.	Roger B, Bettina C, Hans KH. Structured electronic health records. Tidsskr Nor Laegeforen, 2014, 134(4): 431-433.
17.	吳文健, 季國忠, 金培生, 等. 關于電子病歷智能化質量控制管理及思考. 江蘇衛生事業管理, 2020, 31(9): 1181-1184.
18.	張董曉, 賈楠, 馬紅玉, 等. 電子病歷在專病門診建設中的價值及應用. 中國醫藥導報, 2020, 17(6): 174-176, 192.
19.	Srigley JR, McGowan T, Maclean A, et al. Standardized synoptic cancer pathology reporting: A population-based approach. J Surg Oncol, 2009, 99(8): 517-524.
20.	孫鳳英, 于修義. 基于胸外科結構化電子病歷的人工智能診斷系統構建實踐. 中國數字醫學, 2018, 13(11): 29-31.
21.	韓天棟, 宋健, 田野. 住院醫師規范化培訓中辯證思維能力的培養. 醫學與哲學, 2020, 41(8): 26-29.
22.	姜杰, 于修義. 基于標準化術語的胸外科結構化電子病歷實踐. 中國肺癌雜志, 2018, 21(4): 256-259.
23.	范陽東, 朱艷玲, 張青, 等. 廣州市住院醫師規范化培訓存在的問題及對策建議. 中國衛生事業管理, 2020, 37(1): 58-61.
24.	Mintz M, Narvarte HJ, O’Brien KE, et al. Use of electronic medical records by physicians and students in academic internal medicine settings. Acad Med, 2009, 84: 1698-1704.
25.	Gliatto P, Masters P, Karani R. Medical student documentation in the medical record: Is it a liability. Mt Sinai J Med, 2009, 76: 357-364.
26.	Hirschtick RE. A piece of my mind. Copyand-paste. JAMA, 2006, 295: 2335-2336.
27.	Verghese A, Brady E, Kapur CC, et al. The bedside evaluation: Ritual and reason. Ann Intern Med, 2011, 155(8): 550-553.
28.	Phoon CK. Must doctors still examine patients? Perspect Biol Med, 2000, 43: 548-561.
29.	Evans RS. Electronic health records: Then, now, and in the future. Yearb Med Inform, 2016, Suppl 1(Suppl 1): S48-S61.
30.	Almulhem A. Threat modeling for electronic health record systems. J Med Syst, 2012, 36(5): 2921-2926.
31.	Bjugn R, Casati B, Norstein J. Structured electronic template for histopathology reports on colorectal carcinomas: A joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology. Hum Pathol, 2008, 39(3): 359-367.
32.	王志剛, 王斌. 胸心外科住院醫師規范化培訓的臨床教學方法探討. 交通醫學, 2020, 34(5): 545-546, 549.
33.	樂三峰. 胸外科臨床教學特點與住院醫師規范化培訓. 臨床醫藥文獻電子雜志, 2020, 7(7): 181, 191.
34.	陳鐘濤, 吳起武. 電子病歷系統應用對住院病案首頁質量的影響. 中國病案, 2020, 21(11): 6-8.
35.	武鷺鴿. 電子病歷在病案管理中的應用與存在問題要點構架. 醫學美學美容, 2020, 29(16): 194.
36.	趙斌. 臨床溝通助力醫生職業素養的精進. 中國急救醫學, 2020, 40(11): 1057-1058.
37.	Maria A A, Wei WL, Maureen L, et al. Impact of electronic medical record use on the patient-doctor relationship and communication: A systematic review. J Gen Intern Med, 2016, 31(5): 548-560.

1. Colicchio TK, Cimino JJ, Del Fiol G. Unintended consequences of nationwide electronic health record adoption: Challenges and opportunities in the post-meaningful use era. J Med Internet Res, 2019, 21(6): e13313.
2. Tierney MJ, Pageler NM, KahanaM, et al. Medical education in the electronic medical record (EMR) era: Benefits, challenges, and future directions. Acad Med, 2013, 88: 748-752.
3. Stephens MB, Gimbel RW, Pangaro L. Commentary: The RIME/EMR scheme: An educational approach to clinical documentation in electronic medical records. Acad Med, 2011, 86: 11-14.
4. Yuan CM, Little DJ, Marks ES, et al. Nephrology Education Research and Development Consortium—NERDC. The electronic medical record and nephrology fellowship education in the United States: An opinion survey. Clin J Am Soc Nephrol, 2020, 15(7): 949-956.
5. Fernando B, Kalra D, Morrison Z, et al. Benefits and risks of structuring and/or coding the presenting patient history in the electronic health record: Systematic review. BMJ Qual Saf, 2012, 21(4): 337-346.
6. Kuo KM, Talley PC, Kuzuya M, et al. Development of a clinical support system for identifying social frailty. Int J Med Inform, 2019, 132: 103979.
7. Furukawa M, Pollack E. Achieving HIMSS stage 7 designation for EMR adoption. Nurs Manage, 2020, 51(1): 10-12.
8. Clunie DA, Dennison DK, Cram D, et al. Technical challenges of enterprise imaging: HIMSS-SIIM collaborative white paper. J Digit Imaging, 2016, 29(5): 583-614.
9. 戴潔, 姜格寧. 肺部多發結節的診斷、分期和治療現狀. 中華胸心血管外科雜志, 2020, 36(9): 562-568.
10. 薛寶函, 高學軍. 肺小結節精準定位的現狀及進展. 臨床肺科雜志, 2019, 24(8): 1543-1546.
11. 程良, 江中輝, 高薇, 等. 肺部惡性磨玻璃結節的外科診治現狀. 中華胸心血管外科雜志, 2019, 35(12): 763-768.
12. 陳萬青, 李賀, 孫可欣, 等. 2014 年中國惡性腫瘤發病和死亡分析. 中華腫瘤雜志, 2018, 40(1): 5-13.
13. 金玉晶, 唐威, 黃遙, 等. 基于低劑量 CT 肺癌篩查的肺癌相關危險因素分析. 中華腫瘤雜志, 2020, 42(3): 222-227.
14. 周麗娜, 吳寧, 趙世俊, 等. 基于高分辨率 CT 特征鑒別同時多原發肺腺癌與肺腺癌伴肺內轉移. 中華腫瘤雜志, 2020, 42(6): 449-455.
15. 邸天男, 葛春蕾. 關于住院醫師規范化培訓的現狀與思考. 繼續醫學教育, 2020, 34(3): 12-14.
16. Roger B, Bettina C, Hans KH. Structured electronic health records. Tidsskr Nor Laegeforen, 2014, 134(4): 431-433.
17. 吳文健, 季國忠, 金培生, 等. 關于電子病歷智能化質量控制管理及思考. 江蘇衛生事業管理, 2020, 31(9): 1181-1184.
18. 張董曉, 賈楠, 馬紅玉, 等. 電子病歷在專病門診建設中的價值及應用. 中國醫藥導報, 2020, 17(6): 174-176, 192.
19. Srigley JR, McGowan T, Maclean A, et al. Standardized synoptic cancer pathology reporting: A population-based approach. J Surg Oncol, 2009, 99(8): 517-524.
20. 孫鳳英, 于修義. 基于胸外科結構化電子病歷的人工智能診斷系統構建實踐. 中國數字醫學, 2018, 13(11): 29-31.
21. 韓天棟, 宋健, 田野. 住院醫師規范化培訓中辯證思維能力的培養. 醫學與哲學, 2020, 41(8): 26-29.
22. 姜杰, 于修義. 基于標準化術語的胸外科結構化電子病歷實踐. 中國肺癌雜志, 2018, 21(4): 256-259.
23. 范陽東, 朱艷玲, 張青, 等. 廣州市住院醫師規范化培訓存在的問題及對策建議. 中國衛生事業管理, 2020, 37(1): 58-61.
24. Mintz M, Narvarte HJ, O’Brien KE, et al. Use of electronic medical records by physicians and students in academic internal medicine settings. Acad Med, 2009, 84: 1698-1704.
25. Gliatto P, Masters P, Karani R. Medical student documentation in the medical record: Is it a liability. Mt Sinai J Med, 2009, 76: 357-364.
26. Hirschtick RE. A piece of my mind. Copyand-paste. JAMA, 2006, 295: 2335-2336.
27. Verghese A, Brady E, Kapur CC, et al. The bedside evaluation: Ritual and reason. Ann Intern Med, 2011, 155(8): 550-553.
28. Phoon CK. Must doctors still examine patients? Perspect Biol Med, 2000, 43: 548-561.
29. Evans RS. Electronic health records: Then, now, and in the future. Yearb Med Inform, 2016, Suppl 1(Suppl 1): S48-S61.
30. Almulhem A. Threat modeling for electronic health record systems. J Med Syst, 2012, 36(5): 2921-2926.
31. Bjugn R, Casati B, Norstein J. Structured electronic template for histopathology reports on colorectal carcinomas: A joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology. Hum Pathol, 2008, 39(3): 359-367.
32. 王志剛, 王斌. 胸心外科住院醫師規范化培訓的臨床教學方法探討. 交通醫學, 2020, 34(5): 545-546, 549.
33. 樂三峰. 胸外科臨床教學特點與住院醫師規范化培訓. 臨床醫藥文獻電子雜志, 2020, 7(7): 181, 191.
34. 陳鐘濤, 吳起武. 電子病歷系統應用對住院病案首頁質量的影響. 中國病案, 2020, 21(11): 6-8.
35. 武鷺鴿. 電子病歷在病案管理中的應用與存在問題要點構架. 醫學美學美容, 2020, 29(16): 194.
36. 趙斌. 臨床溝通助力醫生職業素養的精進. 中國急救醫學, 2020, 40(11): 1057-1058.
37. Maria A A, Wei WL, Maureen L, et al. Impact of electronic medical record use on the patient-doctor relationship and communication: A systematic review. J Gen Intern Med, 2016, 31(5): 548-560.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Application of structured electronic medical records for pulmonary nodules in standardized training of resident physicians

Abstract Full text Figures/Tables Video References Cited by

Previous Article

Next Article

Format

Content