人工智能时代的电子病历交互设计

1. 引言：电子病历的演变与人工智能的曙光

电子病历（EHR）的广泛采用最初旨在通过提高效率和改善患者护理来革新医疗保健行业 ¹。从本质上讲，电子病历旨在解决与纸质记录相关的诸多问题，例如缺乏标准化、难以搜索以及信息容易丢失等 ²。然而，尽管电子病历拥有巨大的潜力，但其广泛应用也带来了意想不到的挑战，尤其是在用户交互方面，这导致医疗专业人员的挫败感，甚至在某些情况下阻碍了医疗效率的提高 ¹。临床医生经常报告花费大量工作时间处理电子病历相关任务，这往往是以牺牲直接患者互动为代价的，从而导致工作量增加和职业倦怠 ²。研究表明，医生花费在病历记录上的时间甚至超过了与患者互动的时间 ⁶。

在医疗保健领域不断发展的背景下，人工智能（AI）已成为一种变革力量，为解决电子病历长期存在的可用性和效率问题提供了潜在的解决方案 ⁹。人工智能驱动的电子病历系统有望提高数据准确性，简化与其他医疗保健技术的集成，提供预测性分析以实现主动护理，并提供临床决策支持，最终目标是改善患者的治疗效果 ⁹。

然而，人工智能在电子病历中的有效性在很大程度上取决于直观且精心设计的用户界面，这些界面能够与临床工作流程无缝集成，并最大限度地减少医疗专业人员的认知负荷 ⁵。如果人工智能集成电子病历的交互设计不当，可能会导致错误、工作流程中断以及对系统缺乏信任，从而可能抵消人工智能带来的益处 ³。因此，本报告旨在对人工智能时代电子病历的交互设计进行全面分析，探讨当前的可用性挑战，人工智能克服这些挑战的潜力，设计人工智能集成电子病历界面的最佳实践，以及对不同医疗专业人员（如医生和护士）的考虑。

2. 当前电子病历交互设计面临的挑战

电子病历交互设计中存在着诸多可用性问题，这些问题在不同的医疗环境中和不同的用户群体中都有所报告。这些问题不仅影响了医疗专业人员的日常工作，还可能对患者安全产生不利影响。

●      工作流程中断： 电子病历经常会打断临床医生正常的临床工作流程，要求他们花费时间在复杂的系统上进行操作，这会偏离既定的工作流程 ⁴。这种中断会导致效率降低和临床医生的挫败感。

●      繁琐的文档记录： 在电子病历中记录患者就诊信息所需的时间和精力常常过大，占用了本应用于直接患者护理的宝贵时间 ²。医生们报告说，他们每天花费在文档记录上的时间非常多 ⁶。

●      信息过载： 临床医生经常需要在电子病历中处理大量数据，包括不相关的信息、显示效果不佳的数据以及过多的警报，这会妨碍他们专注于关键细节 ⁴。由于复制粘贴造成的“笔记臃肿”进一步加剧了这个问题 ⁸。

●      复杂的用户界面： 许多医疗专业人员发现电子病历系统在技术上难以使用，复杂的导航和不直观的工作流程导致了他们的沮丧和效率低下 ⁴。

●      数据输入困难： 鉴于临床医生的工作流程，将数据输入电子病历的过程可能很麻烦且容易出错 ⁶。不明确的界面可能导致数据输入错误，例如身高和体重信息被互换 ¹⁷。

●      警报问题： 电子病历警报经常不充分，在需要时缺失、不正确、不明确或过于频繁，导致警报疲劳，并可能错过关键通知 ⁴。

●      互操作性问题： 同一电子病历系统不同组件之间或不同电子病历系统之间缺乏无缝的信息交换阻碍了沟通和护理协调 ¹。例如，在急诊科下的药物医嘱可能在患者入院后对临床医生不可见 ¹⁷。

●      视觉显示问题： 电子病历中混乱、杂乱或不准确的信息显示使得临床医生难以有效地解读患者数据 ³。问题包括难以阅读的文本、颜色使用不一致以及未标记的数字 ³。

●      信息可访问性挑战： 临床相关信息通常难以在电子病历中找到，可能被输入到错误的位置或在需要用于患者护理决策时无法访问 ⁶。

●      系统自动化和默认设置： 电子病历系统有时会自动填充或默认设置为意外、不可预测或对临床医生不透明的信息，从而导致医嘱或文档记录中可能出现错误 ⁴。

●      缺乏工作流程支持： 电子病历工作流程可能与最终用户的认知过程和预期操作不一致，从而导致系统设计与临床医生需求之间存在不匹配 ⁴。

这些可用性问题对临床医生的职业倦怠、工作满意度和患者安全产生了重大影响。研究表明，电子病历可用性不足是导致医生和高年资执业护士职业倦怠和工作不满意程度令人担忧的重要因素 ⁵。护士的研究也表明，较差的电子病历可用性与较高的职业倦怠、工作不满意度和离职意愿相关 ¹⁶。更令人担忧的是，较差的电子病历可用性已成为患者安全的一个严重威胁，与实际发生的和险些发生的医疗不良事件（包括用药错误和输错血制品）有关 ³。由于数据在整个护理过程中具有即时可见性，电子病历中的错误可能比纸质病历中的错误更危险 ³。据报道，较差的可用性是导致相当比例的电子病历相关不良患者安全事件的一个促成因素 ⁸。这些长期存在的可用性问题凸显了探索和实施创新解决方案的迫切需要，以改善临床医生的体验并提高患者的安全性 ³。人工智能为解决这些挑战提供了一条有希望的途径，通过提供能够简化工作流程、提高数据准确性并增强电子病历系统整体可用性的工具和功能 ⁹。分析用户与人工智能的交互模式可以帮助识别当前电子病历界面中的具体痛点，为开发更直观和以用户为中心的设计铺平道路 ²²。

3. 人工智能在革新电子病历交互方面的潜力

人工智能为增强电子病历的可用性提供了一个重要的机会，通过分析用户与系统的交互方式来识别困难领域，并为开发更直观的界面提供信息 ²²。人工智能在电子病历中的应用范围广泛，涵盖了从基本的数据输入到复杂的临床决策支持的各个方面。

●      智能数据输入和管理： 人工智能技术，特别是自然语言处理（NLP）和语音识别，可以通过从口语和非结构化文本中提取信息来自动执行数据输入过程，从而显著减少手动记录所需的时间和精力 ⁹。这还可以通过最大限度地减少人为错误来提高数据准确性 ⁹。人工智能还可以优化电子病历中患者数据的组织和管理，使临床医生能够更快、更轻松地在护理点访问他们需要的特定信息，从而提高效率并降低忽略关键细节的风险 ⁹。

●      人工智能驱动的临床决策支持和预测分析： 人工智能算法可以分析大量的患者数据，为临床医生提供实时、循证的诊断和治疗建议，从而可能实现更准确和及时的干预 ⁹。人工智能驱动的预测分析可以识别出患特定疾病或发生不良事件的高风险患者，从而实现主动干预和个性化护理计划 ⁹。

●      自动化管理任务和简化工作流程： 人工智能可以自动执行电子病历系统中的各种管理任务，例如预约安排、计费流程、保险验证和预先授权，从而减轻医疗保健人员的行政负担，使他们能够更多地专注于直接患者护理 ⁹。

●      个性化患者护理和药物管理： 人工智能驱动的分析可以分析患者的个人数据，包括病史、基因信息和生活方式因素，以提供有针对性的健康建议、药物管理和生活方式指导，从而实现更有效和个性化的治疗方案 ⁹。人工智能还在药物管理中发挥着至关重要的作用，可以检测潜在的药物相互作用，建议合适的剂量，并监测患者的依从性 ⁹。

人工智能在电子病历中的广泛集成表明，人们正在共同努力利用其多样化的功能来解决医疗保健生态系统中的各种痛点。通过自动化管理任务和提供智能临床支持，人工智能可以直接减轻医疗专业人员的认知负担和时间限制，从而可能提高他们的工作满意度，并使他们能够将更多的时间和精力投入到患者护理中。人工智能在电子病历中的广泛有效实施有可能将医疗保健从被动模式转变为更主动和个性化的模式，从而实现更早的疾病检测、更具针对性的治疗以及最终更好的患者治疗效果，同时优化资源利用并降低医疗保健成本。

4. 设计以用户为中心的人工智能集成电子病历界面：最佳实践

人工智能集成电子病历界面的有效设计必须以深刻理解人类认知和行为为基础，确保人工智能增强人类能力，而不是制造新的可用性障碍。以人为中心的设计和人机交互（HCI）原则为创建不仅技术先进而且直观、高效且令医疗专业人员满意的AI系统提供了一个强大的框架 ⁶⁸。

●      以人为中心的人工智能原则： 医疗保健人工智能技术的开发应优先考虑人类的需求、价值观和能力，以确保这些系统增强人类的能力，而不是取代或削弱人类的作用 ⁶⁸。以人为中心的人工智能方法需要跨学科合作，并积极让最终用户（包括医疗专业人员）参与到设计过程中，以创建透明、可解释和负责任的人工智能系统 ⁶⁸。伦理考量，包括隐私、公平性和透明度，必须置于医疗保健人工智能设计的最前沿，以防止偏见并确保负责任和值得信赖的人工智能决策 ⁶⁸。人工智能系统应设计为能够适应和学习人类行为，具有情境感知能力，以便在临床工作流程中提供相关且及时的支持 ⁶⁸。用户的持续反馈对于人工智能系统的迭代改进至关重要，确保它们始终符合人类需求和不断发展的临床实践 ³。

●      人工智能驱动功能中的直观导航和清晰的信息层级： 电子病历界面应根据医疗实践的具体工作流程进行定制，简化导航并以直观的方式组织信息，以提高用户满意度并减少认知负荷 ¹²。简约的设计方法，强调基本信息并有效利用负空间，可以减少混乱和干扰，使用户能够专注于关键数据和操作 ¹³。通过策略性地使用大小、颜色和间距建立清晰的视觉层级有助于引导用户的注意力，并使他们能够快速找到人工智能驱动功能中的重要信息 ¹⁴。

●      确保人工智能驱动功能的连贯性、可见性和易学性： 在整个电子病历平台（包括人工智能集成组件）中保持一致的布局、术语和设计元素对于创建熟悉的环境至关重要，这可以缩短学习曲线并增强用户的信心 ¹³。重要信息（例如人工智能生成的警报、建议和人工智能驱动流程的状态）应在电子病历界面中清晰可见且易于访问 ¹³。人工智能驱动的电子病历功能应设计为易于学习，具有直观的工作流程和清晰的说明，最大限度地减少用户掌握和高效工作所需的时间 ¹³。

●      人工智能交互中的错误预防和恢复机制： 人工智能集成电子病历界面应包含防止用户出错的功能，例如智能输入验证、下拉菜单和自动填充功能 ¹⁴。当确实发生错误时，系统应提供清晰、简洁且可操作的错误消息，指导用户如何更正错误并继续完成任务 ¹³。实施允许用户轻松撤消操作或恢复通过人工智能交互所做的意外更改的机制可以增强可用性并减少用户的挫败感 ¹³。

●      数据可视化在人工智能驱动的洞察中的作用： 人工智能驱动的电子病历应利用数据可视化技术（例如图表、图形和仪表板）以清晰、简洁且易于理解的方式呈现复杂的分析见解，从而帮助临床决策 ¹⁴。可视化应该是交互式的，允许用户更详细地探索数据并自定义视图以专注于与其特定需求和任务最相关的信息 ⁷³。

●      针对不同用户群体（包括残疾人士）的可访问性考虑： 人工智能集成电子病历界面必须遵守可访问性标准（例如 WCAG 指南），以确保所有个人（包括视力、听力、运动或认知障碍人士）都能够使用 ¹⁴。诸如可调整的字体大小、高对比度模式、屏幕阅读器兼容性和键盘导航等可访问性功能应纳入人工智能驱动电子病历功能的整体设计中 ¹⁴。

人工智能集成电子病历界面的有效设计必须基于对人类认知和行为的深刻理解，确保人工智能增强人类能力，而不是制造新的可用性障碍。以人为中心的设计和人机交互（HCI）原则为创建不仅技术先进而且直观、高效且令医疗专业人员满意的AI系统提供了一个强大的框架。通过遵守既定的界面设计最佳实践，例如保持一致性、提供清晰的反馈和确保可访问性，开发人员可以显著提高人工智能驱动电子病历功能的可用性，从而提高用户采用率并更好地实现人工智能在医疗保健领域的潜在益处。以用户为中心的人工智能集成电子病历设计方法有可能促进医疗专业人员与技术之间更积极和富有成效的关系，最终有助于建立更高效、更安全和更高质量的医疗保健系统。当人工智能的实施以最终用户体验为中心时，它可以成为一种有价值的工具，赋予临床医生权力并支持他们为患者提供最佳护理。

5. 满足医疗专业人员的需求和关切

医生通常对人工智能在电子病历中的潜力持积极态度，预计人工智能将带来诸多益处，例如减少行政负担、提高工作效率和增强诊断能力 ⁴³。许多人预计人工智能将在未来一年内改变他们的执业方式 ⁸⁰。绝大多数医生认为人工智能可以显著减少文档记录和图表记录等行政任务，从而腾出更多时间用于直接患者互动 ⁴³。医生们还期望人工智能通过提高诊断准确性、提供个性化治疗建议和改善临床决策支持来积极影响临床结果 ⁴³。有些人还预见到人工智能对其执业的财务业绩产生积极影响 ⁸⁰。尽管如此，医生们仍然存在犹豫和担忧，主要与数据隐私和安全、人工智能使用引发的伦理困境以及与现有电子病历系统集成不良的可能性有关 ⁸¹。许多人认为，人工智能解决方案应由其电子病历供应商开发，并由医疗保健专家设计，以确保其适用于现实世界的临床护理 ⁸⁰。医生们强调需要了解人工智能算法如何做出决策的透明信息、在类似实践中展示的实用性以及关于人工智能性能持续监控的信息 ⁸¹。

与医生相比，护士对人工智能在电子病历中的应用表现出更为谨慎和矛盾的态度，她们的主要担忧集中在人工智能对患者安全、护理质量和她们职业实践完整性的潜在影响上 ¹⁶。护士们的主要担忧包括人工智能可能缺乏安全患者护理所需的人类直觉和整体视角、算法偏见和不准确的风险以及担心失去在关键患者护理决策中的自主权 ⁸⁵。她们担心人工智能生成内容的可靠性和准确性以及患者安全风险可能增加 ⁸⁵。护士们尤其担心人工智能使用增加可能导致的人际互动减少以及技术可能侵蚀护患关系 ⁸⁶。虽然护士们也对人工智能减轻文档记录负担的潜力感兴趣，但她们更倾向于自动化行政任务的解决方案，而不是那些直接影响她们临床工作流程或日程安排的解决方案 ²³。人工智能在电子病历中的可用性差是护士们非常关心的问题 ⁶。护士们强调理解她们收集的数据与她们使用的人工智能技术之间的关系的重要性，并且希望有意义地参与人工智能开发和实施的各个阶段 ⁹¹。她们还需要充分的培训和持续的支持才能有效地使用人工智能工具 ⁹⁴。

为了确保人工智能成为一种支持工具，必须在人工智能系统和医疗专业人员之间建立有效的协作策略。人工智能应旨在增强而非取代医疗专业人员的专业知识和判断力，充当支持临床决策的认知辅助工具 ⁵。人为监督和推翻人工智能预测的能力至关重要，尤其是在关键的医疗情况下 ⁹⁸。建立一个协作环境，使人工智能工具与人类专业知识相结合，并明确责任和义务，对于建立信任和确保人工智能的安全有效应用至关重要 ¹⁰。医疗机构应优先开发透明且可解释的人工智能模型，使临床医生能够理解人工智能生成的建议和推荐背后的逻辑，从而做出知情的决策 ¹⁰。

为了弥合知识差距并建立信任，培训和持续支持对于人工智能的采用至关重要。全面且持续的培训计划对于使医疗专业人员掌握有效使用人工智能集成电子病历系统所需的知识和技能至关重要，同时也能解决他们对缺乏理解的担忧 ¹⁰。培训应考虑到最终用户的多样性，并以易于理解的格式和语言提供 ⁹⁸。建立超级用户的入职计划并提供持续的技术和教育支持对于成功采用人工智能和提高医疗保健人员的信心至关重要 ¹。

6. 人工智能驱动的电子病历系统和功能示例

领先的电子病历供应商正在积极投入并将人工智能集成到其平台中，以增强医疗保健服务的各个方面。

●      Epic： 作为领先的电子病历供应商，Epic 一直积极在其软件中集成生成式人工智能，以改善临床医生的工作流程、增强患者体验、简化收入周期流程并加速临床干预 ⁴⁹。这包括用于就诊前计划、患者信息汇总、协助文档记录（病程记录、出院医嘱）以及自动化预先授权和编码等管理任务的人工智能代理 ⁴⁹。Epic 还集成了来自 Abridge 的环境监听软件，并正在探索多模式文档工具 ⁵¹。

●      Oracle Health（前身为 Cerner）： 推出了基于 Oracle 云基础设施构建的下一代电子病历，在整个临床工作流程中嵌入了人工智能。关键的人工智能功能包括 Oracle Health Clinical AI Agent，该功能提供语音驱动的导航、人工智能驱动的摘要、自动化临床文档记录以及后续操作建议。Oracle Health Data Intelligence 旨在提供实时洞察和个性化护理计划 ⁵⁴。

●      Praxis EMR： 这是一个基于人工智能的电子病历系统，它利用神经网络学习医生的图表记录习惯，允许自由文本记录并智能检索相关信息以用于类似的患者病例，从而显著减少了图表记录时间 ³³。

●      eClinicalWorks： 集成了 ChatGPT 等人工智能工具，以帮助汇总患者就诊信息和收集信息，以及用于自动化管理任务和简化电子病历导航的人工智能驱动功能 ⁵⁹。

这些系统集成了环境监听、人工智能抄写员、诊断支持和治疗建议等特定的人工智能功能。环境监听和人工智能抄写员技术利用人工智能实时转录和总结患者与医生之间的对话，自动生成临床笔记，从而减轻文档记录负担 ⁴⁶。例如，Epic 与 Abridge 集成，而 eClinicalWorks 则使用 Sunoh.ai ¹⁰¹。人工智能算法还用于分析医学图像（例如与电子病历集成的 Aidoc 平台）、解读实验室结果并向临床医生提供诊断建议，从而可能提高诊断的准确性和速度 ⁹。此外，人工智能还用于分析患者数据和医学文献，以提出个性化的治疗方案，包括药物建议和治疗计划的潜在调整 ⁹。

这些示例中提到的用户界面设计方面包括语音驱动的导航、对话式搜索和集成的人工智能助手。例如，Oracle Health 的新电子病历具有语音驱动的导航和多模式搜索功能，旨在简化临床医生的工作流程 ⁵⁴。eClinicalWorks 推出了业界首个对话式电子病历界面，允许用户使用自然语言提问来收集患者信息 ¹⁰⁹。许多电子病历系统都集成了人工智能驱动的虚拟助手，这些助手可以响应语音命令、快速访问患者数据并自动执行日常任务 ⁹。

| EHR 系统 | AI 功能 ||---|---|

| Epic | 生成式 AI 用于患者消息、交班总结、患者摘要、临床决策支持、行政任务自动化、多模式文档 49 |

| Oracle Health | Clinical AI Agent（语音导航、多模式搜索、图表审查摘要、自动化文档、医嘱和编码）、Data Intelligence（个性化护理计划） 54 |

| Praxis EMR | 基于神经网络的 Concept Processing，自由文本记录，智能病例匹配，即时生成病历 33 |

| eClinicalWorks | ChatGPT 集成，AI 助手（自然语言查询），Image AI（传真管理），AI for RPA（自动化播放列表），healow No-Show 预测 59 |

7. 人工智能在电子病历交互设计中的可用性评估和未来方向

评估人工智能集成电子病历的可用性和有效性需要采用多种方法，包括用户测试和反馈收集。医疗机构应利用临床相关的测试用例来评估其电子病历系统（包括人工智能驱动的功能）相关的特定可用性和安全风险 ⁶。分析电子病历的使用数据可以为临床医生如何与系统交互提供宝贵的见解，有助于识别构成可用性和安全挑战的领域 ¹⁷。在真实临床环境中对不同最终用户群体进行可用性测试对于评估人工智能集成电子病历界面的有效性和用户满意度至关重要 ³。建立持续的反馈机制，以收集医疗专业人员对人工智能驱动电子病历功能体验的意见，对于持续改进至关重要 ³。

改进电子病历中人工智能的可用性是一个迭代过程，需要根据用户反馈和实际使用模式进行持续的监控、评估和改进 ³。人工智能开发人员应在人工智能工具的整个生命周期中积极与医疗专业人员互动，以了解他们的需求、预测障碍并促进接受和采用 ⁹⁸。

人工智能在电子病历交互设计方面的未来可能会更加侧重于基于意图的界面，用户可以用自然语言表达他们的目标，人工智能将协助实现这些目标，这可能会与传统的图形用户界面元素相结合 ¹²⁰。多模式人工智能的进步将使电子病历能够处理和理解文本以外的各种形式的数据，例如视频、图像和音频，从而实现更丰富、更全面的临床文档记录和分析 ⁵¹。能够自主执行任务、与患者互动并为临床医生提供主动支持的更复杂的人工智能代理的开发是未来的一个可能方向 ²⁹。

在设计和部署电子病历中的人工智能时，必须认真对待伦理影响、数据隐私和安全性。在整个设计和实施过程中，必须认真对待伦理考量，包括透明度、公平性、责任以及人工智能算法中潜在的偏见 ¹⁰。在将人工智能集成到电子病历系统时，强大的数据隐私和安全措施对于保护敏感的患者信息至关重要，需要遵守 HIPAA 和 GDPR 等法规 ¹⁰。确保电子病历中使用的人工智能算法的可靠性和准确性对于维持医疗专业人员的信任和避免对患者造成潜在伤害至关重要 ¹⁰。人工智能系统的工作方式及其建议背后的推理过程的透明度对于建立信任并使临床医生能够做出知情的决策至关重要 ¹⁰。

8. 结论：迈向更智能、更友好的电子病历体验

人工智能在电子病历交互设计方面面临着挑战，但也带来了巨大的机遇。人工智能有潜力将电子病历从令人沮丧和负担的来源转变为有价值的临床资产，从而提高效率，改善患者护理并减轻临床医生的职业倦怠。然而，要实现这种变革潜力，以人为中心的方法至关重要，确保人工智能工具的设计始终将医疗专业人员的需求和工作流程放在首位。人工智能驱动的电子病历的未来在于创造一个智能、直观且安全的系统，该系统能够增强医疗保健专业人员的能力，最终改善患者的治疗效果。

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