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更新时间:2009-5-21:  来源:毕业论文

医生处方系统论文
英文文献
Determinants of physician use of an ambulatory prescription expert systemSummary
Abstract
Purpose:
To determine whether physician experience with and attitude towards computers is associated with adoption of a voluntary ambulatory prescription writing expert system.
Methods:
A prescription expert system was implemented in an academic internal medicine residency training clinic and physician utilization was tracked electronically. A physician attitude and behavior survey (response rate = 89%) was conducted six months after implementation.
Results:
There was wide variability in system adoption and degree of usage, though 72% of physicians reported predominant usage (≥50% of prescriptions) of the expert system six months after implementation. Self-reported and measured technology usage were strongly correlated (r = 0.70, p < 0.0001). Variation in use was strongly associated with physician attitude toward issues of system efficiency and effect on quality, but not with prior computer experience, level of training, or satisfaction with their primary care practice. Non-adopters felt that electronic prescribing was more time consuming and also more likely to believe that their patients preferred hand-written prescriptions.
Conclusion:
A voluntary electronic prescription system was readily adopted by a majority of physicians who believed it would have a positive impact on the quality and efficiency of care. However, dissatisfaction with system capabilities among both adopters and non-adopters suggests the importance of user education and expectation management following system selection.
Keywords:
Electronic medical records; Prescription expert system; Physician attitudes; Physician behavior
1. Introduction
In an era of increasing technological innovation in the administration and delivery of health care, the calls to accelerate the automation of clinician documentation are loud and clear. Despite the fact that physicians play a key role, relatively little is known about how physician attitudes toward such change impact successful implementation of electronic medical record systems (EMR). Though there are many published reports on information technology adoption among nurses and some concerning physicians in hospital settings,the literature is sparse with respect to primary care physician attitude toward and use of ambulatory computer systems.
Davis’ ‘Technology Acceptance Model’ has been widely used to explain technology acceptance based on perceived ease of use and usefulness.Extending this work to medical informatics, Dixon conceptualized an ‘Information Technology Adoption Model’ and likewise found that perceived usefulness and ease of use were critical to self-reported adoption of computer systems in a survey of Canadian primary care physicians. Similarly, Dansky et al demonstrated that perceived organizational support and physician computer experience were positively associated with perceived usefulness of electronic records while computer anxiety and valuing close patient relationships were negative predictors of perceived utility. However, in neither Dixon nor Dansky's surveys were physicians actually using electronic records (i.e. talking from experience) and both studies relied on self-report. Cork et al surveyed 771 academic physicians from five institutions regarding computers, but without respect to any specific systems implementation. They also found that favorable attitudes toward computers and technologic sophistication were positively associated with reported usage. Gadd and Penrod have examined physician attitudes toward ambulatory EMR use before and six months after EMR implementation. They reported diminished enthusiasm after the fact across multiple domains, but especially with respect to attitudes about system efficiency and usability. The authors, however, did not report on physician characteristics that might be associated with particular attitudes or adoption.
We studied the implementation of a computer-based prescription expert system in an internal medicine resident and faculty practice to evaluate the relationship between physician characteristics and technology adoption. Since use of the system was encouraged but not mandated, we sought to determine whether physician computer experience and attitudes were associated with actual adoption of this innovation. Our goal was to discover whether these or other barriers were a substantial implementation impediment that would warrant targeted training and educational interventions.
2. Methods
The study setting was an internal medicine resident and faculty practice serving a predominantly indigent population in central Virginia. The 94 physician practice averaged approximately 28,000 patient visits per year. The prescription expert system (Practice Partner® v7.5, Physician Micro Systems, Inc.) was implemented in September 2003 and enabled electronic maintenance of a medication list, printing and renewing prescriptions, and checking of drug–drug and drug–allergy interactions. The system did not have a medication knowledge base other than that pertaining to interactions. Use of the system was voluntary though strongly encouraged. A six months post-implementation survey of the practice's physicians assessed use of and attitude toward the expert system, attitudes toward computers in general, prior computer experience, as well as career path and demographics. The survey was administered by mail with a reminder sent after two weeks to non-respondents. Data on actual physician adoption of the expert system was available as the electronic log of prescriptions written since system implementation.
The computer attitude scale was derived from one previously validated by Cork et al. Their 16 item ‘computer optimism’ scale was unidimensional by factor analysis and we incorporated 8 of the top 9 loading items from this scale in our survey. These eight items were those most directly relevant to our purpose, assessing computer effect on doctor–patient rapport, quality of care, humaneness, patient satisfaction, teamwork, autonomy, cost, and ‘enjoyment’ of medical practice. These items were rated on a scale of 1–5 with 1: highly detrimental and 5: highly beneficial, with three being neutral. Human subjects approval was obtained prior to conducting the physician survey from the University of Virginia Human Investigations Committee.
We evaluated the association of self-reported versus actual adoption and the relationship between adoption and computer attitudes, experience, demographic characteristics, and primary care interest. We used analysis of variance (SAS v8.02) with number of prescriptions written by each physician in the past two months as the dependent variable and the physician characteristics as independent variables. A two-tailed p-value of 0.05 was the criterion for statistical significance.
3. Results
The survey was completed by 84 (89%) of the practice clinicians. Table 1 demonstrates that the respondents were balanced across level of training, fairly computer literate, and predominantly subspecialty focused. Table 2 contains respondent attitude and self-reported utilization data, indicating general agreement with potential quality-based benefits of a prescription expert system but differing responses with respect to aspects of efficiency, training, preference, satisfaction, and adoption.
Respondents also rated whether they perceived the effect of omputers on medicine to be detrimental or beneficial with respect to eight attitudinal items that reflected the impact of computers on their enjoyment of medical practice, rapport with patients, quality of care, humaneness, patient satisfaction, physician communication, physician autonomy, and health care costs. Overall, the mean attitude toward computers (averaging the eight items) was 3.9 with individual item means ranging from 3.1 (effect on humaneness of the practice of medicine) to 4.6 (effect on quality of care) on the five point scale. Thus, most physicians had favorable attitudes toward the impact of computers on the practice of medicine.
There was a strong association between self-reported rate of recent system use and the actual number of prescriptions written in the two months prior to the survey based on electronic utilization data (r = 0.70, p < 0.0001). Those respondents reporting that they had not yet adopted electronic prescribing all had very low actual utilization and those reporting recent adoption had their predominant system usage in the two months preceding the survey.
System utilization rate (the number of electronic prescriptions written by each physician during the study period) was strongly associated with attitudes towards the expert system reflective of actual ease of use and usefulness (Table 3). Physicians believing that their patients liked them to use the system wrote far more electronic prescriptions on average as did those who felt it was helpful for organizing the medication list. Physicians with

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