Participants’ characteristics.

Digital advancements can reduce the burden of recording clinical information. This intra-subject experimental study compared the time and error rates for recording vital signs and prescriptions between an optical character reader (OCR) and manual typing. This study was conducted at three community hospitals and two fire departments in Japan. Thirty-eight volunteers (15 paramedics, 10 nurses, and 13 physicians) participated in the study. We prepared six sample pictures: three ambulance monitors for vital signs (normal, abnormal, and shock) and three pharmacy notebooks that provided prescriptions (two, four, or six medications). The participants recorded the data for each picture using an OCR or by manually typing on a smartphone. The outcomes were recording time and error rate defined as the number of characters with omissions or misrecognitions/misspellings of the total number of characters. Data were analyzed using paired Wilcoxon signed-rank sum and McNemar’s tests. The recording times for vital signs were similar between groups (normal state, 21 s [interquartile range (IQR), 17–26 s] for OCR vs. 23 s [IQR, 18–31 s] for manual typing). In contrast, prescription recording was faster with the OCR (e.g., six-medication list, 18 s [IQR, 14–21 s] for OCR vs. 144 s [IQR, 112–187 s] for manual typing). The OCR had fewer errors than manual typing for both vital signs and prescriptions (0/1056 [0%] vs. 14/1056 [1.32%]; p<0.001 and 30/4814 [0.62%] vs. 53/4814 [1.10%], respectively). In conclusion, the developed OCR reduced the recording time for prescriptions but not vital signs. The OCR showed lower error rates than manual typing for both vital signs and prescription data.

数字化技术进步可减轻临床信息记录的工作负担。本项受试者内实验研究对比了光学字符识别（OCR）与手动录入两种方式下，生命体征与处方信息的记录时长及错误率。本研究于日本的3家社区医院及2个消防部门开展，共有38名志愿者参与，其中包括15名急救医护人员、10名护士及13名医师。我们准备了6份样本素材：3份用于展示生命体征的救护车监护仪画面（分别对应正常状态、异常状态及休克状态），以及3份包含处方信息的药房处方本（分别标注2种、4种或6种药品）。参与者需分别通过OCR或在智能手机上手动录入的方式，记录每份样本素材中的信息。本研究的结局指标为记录时长与错误率，其中错误率定义为存在遗漏、误识别/拼写错误的字符数占总字符数的比例。数据采用配对Wilcoxon符号秩和检验与McNemar检验进行分析。生命体征的记录时长在两组间无显著差异：正常状态下，OCR组为21秒[四分位间距（IQR）：17~26秒]，手动录入组为23秒[四分位间距（IQR）：18~31秒]。相较而言，OCR组的处方记录时长更短：以6种药品的处方清单为例，OCR组为18秒[IQR：14~21秒]，手动录入组则为144秒[IQR：112~187秒]。无论是生命体征记录还是处方记录，OCR组的错误率均低于手动录入组：生命体征记录组错误率为0/1056（0%）vs. 手动录入组14/1056（1.32%），p<0.001；处方记录组错误率为30/4814（0.62%）vs. 手动录入组53/4814（1.10%）。综上，本研究开发的OCR系统可缩短处方信息的记录时长，但对生命体征记录时长无显著改善；且无论是生命体征还是处方数据的记录，OCR的错误率均低于手动录入方式。