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Hoitotyön kirjaamisessa tunnistettujen ongelmien selvittämiseksi toteutettiin keväällä 2010
tutkimus, jossa arvioitiin sekä kansallisen kirjaamismallin, että
potilastietojärjestelmätoteutusten käytettävyyttä terveydenhuollon organisaatioissa. Hankkeen loppuraportti on saatavissa osoitteesta:
http://www.cs.uta.fi/reports/dsarja/D-2010-7.pdf

Tutkimuksen tavoitteena oli arvioida:
1) Kansallisen hoitotyön kirjaamismallin käytettävyyttä.
2) Hoitokertomusten käytettävyyttä valituissa potilastietojärjestelmissä.
3) Hoitotyön prosessimallin, luokitusten ja hoitokertomusten soveltuvuutta ja
käytettävyyttä moniammatillisessa hoitotyössä, erityisesti tiedonvälityksessä
lääkärien ja hoitohenkilökunnan kesken.

Tutkimuksen tulokset osoittavat ongelmia sekä kirjaamismallissa, tietojen
moniammatillisessa hyödyntämisessä että hoitokertomuksissa. Kirjaamismalli on liian
yksityiskohtainen ja hienojakoinen ja mallin mukaan kirjattaessa potilaan
hoitoprosessi pilkkoutuu pieniin osiin ja tietojen hyödynnettävyys ja saatavuus on
hankalaa. Hoitokertomukset, eli kirjaamismallin tietojärjestelmätoteutukset eri
potilaskertomusjärjestelmissä poikkeavat toisistaan ja toteutuksissa on paljon
käytettävyysongelmia. Hoitokertomusten käyttö vaatii muistamista, ulkoa opettelua,
mekaanista klikkailua ja paljon työaikaa.

Tutkimuksen tuloksena suositellaan, että kirjaamismallia yksinkertaistetaan ja
selkiytetään sekä kirjaamiskäytäntöön kehitetään eri tilanteisiin sopivia mallipohjia,
jotka auttavat kirjaamismallin soveltamisessa erilaisissa ympäristöissä. Hoitotyön
kirjausten moniammatillista hyödyntämistä tulee parantaa siten, että kirjaamismallin
kehittämisessä otetaan huomioon muiden hoitotyöhön osallistuvien ammattiryhmien
tietojen dokumentointija hyödyntämistarpeet ja erityisesti lääkäreille tuotetaan oma,
yhteenvedonomainen näkymä hoitokertomustietoihin.

Hoitokertomusten, eli tietojärjestelmätoteutusten käytettävyyttä tulee parantaa.
Nykyisissä toteutuksissa on runsaasti käytettävyysongelmia, jotka hankaloittavat
hoitokertomusten käyttöä. Hoitokertomustoteutusten eri potilastietojärjestelmissä
tulisi olla yhtenäisempiä kuin ne nyt ovat, ja hoitokertomusten tulisi tukea nykyistä
paremmin käytännön hoitotyötä.

Tutkimus toteutettiin aikavälillä 1.1.1.6.2010 ja tutkimuksen rahoittivat työsuojelurahasto (TSR, rahoituspäätös 109314) ja Sosiaali- ja terveysministeriö (STM). Tutkimuksen vastuullinen organisaatio oli Tampereen yliopisto, tietojenkäsittelytieteiden laitos, eHealth tutkimus, vastuuhenkilönä professori Pirkko Nykänen, ja tutkijoina hankkeessa olivat TtM, YtK, esh Anne Kuusisto, Satakunnan
sairaanhoitopiiri, Tietopalvelukeskus ja TkL Johanna Viitanen, Aalto yliopiston teknillinen korkeakoulu, Strategisen käytettävyyden tutkimusryhmä.

Uutinen ja kymmenittäin aiheeseen liittyviä kommentteja:

http://www.hs.fi/kotimaa/artikkeli/Kankeat+tietoj%C3%A4rjestelm%C3%A4t+tuhlaavat+l%C3%A4%C3%A4k%C3%A4reiden+ty%C3%B6aikaa/1135251672311

Ilmeisesti HS:n uutinen oli osittain virheellinen. Aiheeseen liittyviä oikaisuja TiVin artikkelissa: http://www.tietoviikko.fi/kaikki_uutiset/article258682.ece.

Mielenkiintoinen artikkeli Lääkärilehdessä "WHOIKE-tietojärjestelmän
käyttöönotto jouduttiin keskeyttämään Etelä-Karjalan keskussairaalassa" löytyy tuolta: http://www.laakarilehti.fi/files/nostot/nosto18_3.pdf. 

Toisin kuin Duodecim odottaa epäilen tästä muodostuvan sairaanhoitajien päätöksentukijärjestelmän.

Duodecimin järjestelmän tavoite on tukea lääkärien päätöksentekoa.

Järjestelmää piloitoidaan tulevien 18 kk aikana rajoitetusti Pegasos  ja (tietääkseni) Effica -tietojärjestelmissä.