电子病历系统核心功能的确定

1、Paper-based records have been in existence for centuries and their gradual replacement by computer-based records has been slowly underway for over twenty years in western healthcare systems. Computerized information systems have not achieved the same degree of penetration in healthcare as that seen

2、in other sectors such as finance, transport and the manufacturing and retail industries. Electronic medical record systems lie at the center of any computerized health information system. Without them other modern technologies such as decision support systems cannot be effectively integrated into ro

3、utine clinical workflow.The 2003 IOM patient safety report describes an EMR as encompassing: "a longitudinal collection of electronic health information for and about persons immediate electronic access to person- and population-level information by authorized users; provision of knowledge and

4、decision-support systems that enhance the quality, safety, and efficiency of patient care and support for efficient processes for health care delivery." IOM, 2003, P4 (footnote).The US IOM report, Key Capabilities of an Electronic Medical Record System Tang, 2003, identified a set of 8 core car

5、e delivery functions that electronic health record systems should be capable of performing in order to promote greater safety, quality and efficiency in health care delivery. They are:Health information and data: Having immediate access to key information - such as patients' diagnoses, allergies

6、, lab test results, and medications - would improve caregivers' ability to make sound clinical decisions in a timely manner. Result management: The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would increase pat

7、ient safety and the effectiveness of care. Order management : The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance legibility, reduce duplication, and improve the speed with which orders are executed. Decision support: Using rem

8、inders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and treatments. Electronic communication and connecti

9、vity: Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events. Patient support: Tools that give patients access to their health records,

10、provide interactive patient education, and help them carry out home-monitoring and self-testing can improve control of chronic conditions, such as diabetes. Administrative processes: Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics'

11、efficiency and provide more timely service to patients. Reporting: Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and disease

12、surveillance." The benefits of EMR can be summarized in the 6 main areasReplace paper-based medical records which can be incomplete, fragmented (different parts in different locations), hard to read and (sometimes) hard to find. Provide a single, shareable, up to date, accurate, rapidly retriev

13、able source of information, potentially available anywhere at any time. Require less space and administrative resources. Potential for automating, structuring and streamlining clinical workflow. Provide integrated support for a wide range of discrete care activities including decision support, monit

14、oring, electronic prescribing, electronic referrals radiology, laboratory ordering and results display. Maintain a data and information trail that can be readily analyzed for medical audit, research and quality assurance, epidemiological monitoring, disease surveillance and support for continuing me

15、dical education.Widespread implementation of EMRs has been hampered by many perceived barriers includingTechnical matters (uncertain quality, functionality, ease of use, lack of integration with other applications.Financial matters - particularly applicable to non-publicly funded health service syst

16、ems (initial costs for hardware and software, maintenance, upgrades, replacement.)Resources issues, training and re-training; resistance by potential users; implied changes in working practices.Certification, security, ethical matters; privacy and confidentiality issuesDoubts on clinical usefulnessI

17、ncompatibility between systems (user interface, system architecture and functionality can vary significantly between suppliers' products).From a dermatologists perspective, even in our resource limited Indian background, adopting EMR not only improves our quality of patient care but also opens a

18、 new horizon of interdisciplinary and peer consultation as well as the chance of self improvement. Unfortunately as mentioned earlier, the financial constraints will be the main hindrance in rapid incorporation of EMR in our country. Fortunately some of the EMR providers have uploaded free but partially limited version of their software. Even in their limited capacity they have enough functionality and are customizable to fulfill majority of a