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：

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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

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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.
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11.	程良, 江中辉, 高薇, 等. 肺部恶性磨玻璃结节的外科诊治现状. 中华胸心血管外科杂志, 2019, 35(12): 763-768.
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13.	金玉晶, 唐威, 黄遥, 等. 基于低剂量 CT 肺癌筛查的肺癌相关危险因素分析. 中华肿瘤杂志, 2020, 42(3): 222-227.
14.	周丽娜, 吴宁, 赵世俊, 等. 基于高分辨率 CT 特征鉴别同时多原发肺腺癌与肺腺癌伴肺内转移. 中华肿瘤杂志, 2020, 42(6): 449-455.
15.	邸天男, 葛春蕾. 关于住院医师规范化培训的现状与思考. 继续医学教育, 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.	吴文健, 季国忠, 金培生, 等. 关于电子病历智能化质量控制管理及思考. 江苏卫生事业管理, 2020, 31(9): 1181-1184.
18.	张董晓, 贾楠, 马红玉, 等. 电子病历在专病门诊建设中的价值及应用. 中国医药导报, 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.	孙凤英, 于修义. 基于胸外科结构化电子病历的人工智能诊断系统构建实践. 中国数字医学, 2018, 13(11): 29-31.
21.	韩天栋, 宋健, 田野. 住院医师规范化培训中辩证思维能力的培养. 医学与哲学, 2020, 41(8): 26-29.
22.	姜杰, 于修义. 基于标准化术语的胸外科结构化电子病历实践. 中国肺癌杂志, 2018, 21(4): 256-259.
23.	范阳东, 朱艳玲, 张青, 等. 广州市住院医师规范化培训存在的问题及对策建议. 中国卫生事业管理, 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.	王志刚, 王斌. 胸心外科住院医师规范化培训的临床教学方法探讨. 交通医学, 2020, 34(5): 545-546, 549.
33.	乐三峰. 胸外科临床教学特点与住院医师规范化培训. 临床医药文献电子杂志, 2020, 7(7): 181, 191.
34.	陈钟涛, 吴起武. 电子病历系统应用对住院病案首页质量的影响. 中国病案, 2020, 21(11): 6-8.
35.	武鹭鸽. 电子病历在病案管理中的应用与存在问题要点构架. 医学美学美容, 2020, 29(16): 194.
36.	赵斌. 临床沟通助力医生职业素养的精进. 中国急救医学, 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. 戴洁, 姜格宁. 肺部多发结节的诊断、分期和治疗现状. 中华胸心血管外科杂志, 2020, 36(9): 562-568.
10. 薛宝函, 高学军. 肺小结节精准定位的现状及进展. 临床肺科杂志, 2019, 24(8): 1543-1546.
11. 程良, 江中辉, 高薇, 等. 肺部恶性磨玻璃结节的外科诊治现状. 中华胸心血管外科杂志, 2019, 35(12): 763-768.
12. 陈万青, 李贺, 孙可欣, 等. 2014 年中国恶性肿瘤发病和死亡分析. 中华肿瘤杂志, 2018, 40(1): 5-13.
13. 金玉晶, 唐威, 黄遥, 等. 基于低剂量 CT 肺癌筛查的肺癌相关危险因素分析. 中华肿瘤杂志, 2020, 42(3): 222-227.
14. 周丽娜, 吴宁, 赵世俊, 等. 基于高分辨率 CT 特征鉴别同时多原发肺腺癌与肺腺癌伴肺内转移. 中华肿瘤杂志, 2020, 42(6): 449-455.
15. 邸天男, 葛春蕾. 关于住院医师规范化培训的现状与思考. 继续医学教育, 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. 吴文健, 季国忠, 金培生, 等. 关于电子病历智能化质量控制管理及思考. 江苏卫生事业管理, 2020, 31(9): 1181-1184.
18. 张董晓, 贾楠, 马红玉, 等. 电子病历在专病门诊建设中的价值及应用. 中国医药导报, 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. 孙凤英, 于修义. 基于胸外科结构化电子病历的人工智能诊断系统构建实践. 中国数字医学, 2018, 13(11): 29-31.
21. 韩天栋, 宋健, 田野. 住院医师规范化培训中辩证思维能力的培养. 医学与哲学, 2020, 41(8): 26-29.
22. 姜杰, 于修义. 基于标准化术语的胸外科结构化电子病历实践. 中国肺癌杂志, 2018, 21(4): 256-259.
23. 范阳东, 朱艳玲, 张青, 等. 广州市住院医师规范化培训存在的问题及对策建议. 中国卫生事业管理, 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. 王志刚, 王斌. 胸心外科住院医师规范化培训的临床教学方法探讨. 交通医学, 2020, 34(5): 545-546, 549.
33. 乐三峰. 胸外科临床教学特点与住院医师规范化培训. 临床医药文献电子杂志, 2020, 7(7): 181, 191.
34. 陈钟涛, 吴起武. 电子病历系统应用对住院病案首页质量的影响. 中国病案, 2020, 21(11): 6-8.
35. 武鹭鸽. 电子病历在病案管理中的应用与存在问题要点构架. 医学美学美容, 2020, 29(16): 194.
36. 赵斌. 临床沟通助力医生职业素养的精进. 中国急救医学, 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

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