毕业设计外文文献-基于计算机的患者记录：医疗保健的基本技术

附录A.外文翻译-原文部分TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCareIntroductionThepatientrecordistheprincipalrepositoryforinformationconcerningapatient'shealthcare.Itaffects,insomeway,virtuallyeveryoneassociatedwithproviding,receiving,orreimbursinghealthcareservices.Despitethemanytechnologicaladvancesinhealthcareoverthepastfewdecades,thetypicalpatientrecordoftodayisremarkablysimilartothepatientrecordof50yearsago.ThisfailureofpatientrecordstoevolveisnowcreatingadditionalstresswithinthealreadyburdenedU.S.healthcaresystemastheinformationneedsofpractitioners,1patients,administrators,third-partypayers,researchers,andpolicymakersoftengounmet.AsdescribedbyEllwood(1988:1550).Theintricatemachineryofourhealthcaresystemcannolongergraspthethreadsofexperience…Toooften,payers,physicians,andhealthcareexecutivesdonotsharecommoninsightsintothelifeofthepatient…Thehealthcaresystemhasbecomeanorganismguidedbymisguidedchoices;itisunstable,confused,anddesperatelyinneedofacentralnervoussystemthatcanhelpitcopewiththecomplexitiesofmodernmedicine.Patientrecordimprovementcouldmakemajorcontributionstoimprovingthehealthcaresystemofthisnation.A1991GeneralAccountingOffice(GAO)reportonautomatedmedicalrecordsidentifiedthreemajorwaysinwhichimprovedpatientrecordscouldbenefithealthcare(GAO),Thecommitteeusesthetermpractitionerstorefertoallhealthcareprofessionalswhoprovideclinicalservicestopatients.Theseprofessionalsinclude,butarenotlimitedto,physicians,nurses,dentists,andtherapists.SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.Addanotetoyourbookmark1991).First,automatedpatientrecordscanimprovehealthcaredeliverybyprovidingmedicalpersonnelwithbetterdataaccess,fasterdataretrieval,higherqualitydata,andmoreversatilityindatadisplay.Automatedpatientrecordscanalsosupportdecisionmakingandqualityassuranceactivitiesandprovideclinicalreminderstoassistinpatientcare.Second,automatedpatientrecordscanenhanceoutcomesresearchprogramsbyelectronicallycapturingclinicalinformationforevaluation.Third,automatedpatientrecordscanincreasehospitalefficiencybyreducingcostsandimprovingstaffproductivity.Severalsourcessupporttheseconclusions.TheGAOreportedthatanautomatedmedicalrecordsystemreducedhospitalcostsby$600perpatientinaDepartmentofVeteransAffairshospitalbecauseofshorterhospitalstays(GAO,1991).Reductionsinthelengthofinpatientstayswerealsofoundinotherstudiesofcomputerizedmedicalrecordsandmedicalrecordsummaries(RogersandHaring,1979).Otherinvestigatorsfoundenhancedcareandimprovedoutcomeofcareforclinicpatients(Rogersetal.,1982)andareductioninmedicationerrors(Garrettetal.,1986).Thefirststeptowardpatientrecordimprovementisacloseexaminationoftheusersofthepatientrecord,thetechnologiesavailabletocreateandmaintainit,andthebarrierstoenhancingit.Tothatend,theInstituteofMedicine(IOM)oftheNationalAcademyofSciencesundertookastudytorecommendimprovementstopatientrecordsinresponsetoexpandingfunctionalrequirementsandtechnologicaladvances.StrengthsandWeaknessesofPaperPatientRecordsThecommittee'sliteraturereviewdidnotrevealanysubstantivedocumentationofthestrengthsofpaperpatientrecords.ThisresultmaybeHealthcareprofessionalsmightmaintainaseparatepatientrecordtoprotectsensitivedata(e.g.,psychiatrichistory)ortosupportaresearchinterest(i.e.,separaterecordscontainingdetaileddataforaresearchproject).Pharmaciescaptureinformationpertinenttopatientcarebutdonotmaintainfullpatientrecords.Informationonthemedicationsprescribedandthespecialtiesofthephysicianswritingtheprescriptionscanprovideenoughinformationtodetermineapatient'smedicalproblems,however,andpharmacyrecordsmaythusraiseconfidentialityissuessimilartothoseassociatedwithpatientrecords.Becausethecommitteefocusedmorecloselyontraditionalpatientcarerecords,thisreportdoesnotaddressissuesrelatedtopharmacyrecords.SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.×Addanotetoyourbookmarkexplainedinpartbythefactsthatthevalueofmaintainingpatientrecordsiswidelyacceptedinthehealthcarecommunityandthatpaperisthemostwidelyusedrecordkeepingform.Giventheprevalenceofpaperpatientrecords,thecommitteenotedthatsupportbypractitionersforthiskindofrecordkeepingshouldnotbeunderestimated.Timeandresourceconstraintsdidnotpermitthecommitteetosurveyuserattitudestowardpaperrecords;however,committeemembersidentifiedatleastfivestrengthsofsuchrecordsfromtheperspectiveofrecordusers:Paperrecordsarefamiliartouserswhoconsequentlydonotneedtoacquirenewskillsorbehaviorstousethem.Paperrecordsareportableandcanbecarriedtothepointofcare.Onceinhand,paperrecordsdonotexperiencedowntimeascomputersystemsdo.Paperrecordsallowflexibilityinrecordingdataandareabletorecord"soft"(i.e.,subjective)dataeasily.Paperrecordscanbebrowsedthroughandscanned(iftheyarenottoolarge).Thisfeatureallowsuserstoorganizedatainvariouswaysandtolookforpatternsortrendsthatarenotexplicitlystated.Criticismofcurrentpatientrecordsissometimessharp.Burnum(1989:484)statesthat"medicalrecords,whichhavelongbeenfaulty,containmoredistorted,deleted,andmisleadinginformationthaneverbefore."Pories(1990:47)relatesthestoryofanengineerwhowasaskedtorecommendmoreefficientuseofhealthcarepersonnelbutwhoinsteadwas"stunnedbythedisorganizationofthemedicalrecordandtheinefficienciesitimposedonthedeliveryofcare."Theengineerconcludedthat"theredesignoftherecordofferedthemostimmediateandsimpleapproachformedicalcostcontrolandforpreventionofmalpractice"(p.47).Poriesbelievesthatthissituationhasnotimprovedandthatitisnotisolated."Noonehasamonopolyontheproblem:medicalrecordsappeartobeequallybadanddangerousthroughouttheland"(Pories1990:47).Heisnotaloneinhisviewthatpatientrecordsoftenlackthefeaturesneededfortheirmostbeneficialuse.Inarecentsurveyofinternistsinacademicandprivatepractice,63percentoftherespondentsagreedwiththestatementthatpatientrecordsarebecomingincreasinglyburdensomewithoutimprovingthequalityofpatientcare(Hersheyetal.,1989).Theweaknessesofpatientrecords,asdescribedintheliteratureandintheworkofthecommittee,canbesubsumedunderfourmainheadings:(1)Althoughflexibilityinrecordingdatamaybeviewedasastrengthbytheindividualrecordingtheinformation,lackofstandardvocabularyandcodingcanposeproblemsforsubsequentusers—includingpractitioners,administrators,researchers,andthird-partypayers.SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.Addanotetoyourbookmarkcontent;(2)format;(3)access,availability,andretrieval;and(4)linkagesandintegration.ProblemswithPatientRecordContentPatientrecorddataareoftenmissing,illegible,orinaccurate(TufoandSpeidel,1971;Zuckermanetal.,1975;Bentsen,1976;Zimmerman,1978;Foxetal.,1979;RommandPutnam,1981;GerbertandHargreaves,1986;Hsiaetal.,1988;Pories,1990).Datacanbemissingforatleastthreereasons:(1)questionswereneverasked,examinationswereneverperformed,ortestswereneverordered;(2)theinformationwasrequestedandprovided,buteitheritwasnotrecordedbytheclinicianordelaysoccurredinplacingtheinformationintherecord;and(3)theinformationwasrequestedanddeliveredbutwasmisplacedorlost.Inaddition,clinicians,patients,orequipmentcanallintroduceerrorsintopatientrecords(Burnum,1989).Manystudieshaveexaminedthequalityofpatientrecordcontent.Table1-1presentsthefindingsofseveralsuchinvestigations.Themissinginformationreportedinthevariousstudiesoftenresultedinadditionalcostsofpatientcare.Forexample,anestimated11percentoflaboratorytestsinonehospitalwereorderedtoduplicatetestsforwhichfindingswereunavailabletothephysicianatthetimeofthepatientvisit(TufoandSpeidel,1971).Althoughforsomerecordsdataaremissing,inothercasescertaindataareexcessiveorredundant(Zimmerman,1978;KorpmanandLincoln,1988).Thethicknessandweightoftherecordsofpatientswithchronicproblemscanbeimposing,ifnotdaunting,andtimeconstraintsmaypreventtheuserfromfindingandusingnecessaryinformation.(Inonestudyofpaperpatientrecords,theaverageweightofaclinicrecordwas1-1/2pounds[Rogersetal.,1982].)Otherissuesrelatedtorecordcontentincludefailuretocapturetherationaleofproviders,lackofstandardizationofdefinitionsofterminology,failuretodescribethepatientexperience,lackofpatient-basedgenerichealthoutcomemeasures,andincomprehensibilityforpatientsandtheirfamilies.ProblemswithAccess,Availability,andRetrievalRecordunavailabilityanddifficultiesinaccessingrecordswhentheyareavailablearefrequentproblemsforpatientrecordusers(Pories,1990).TufoandSpeidel(1971)documentedintheirstudythatmedicalrecordswereunavailableinupto30percentofpatientvisits.Theyattributedthisrateofunavailabilitytoseveralpossiblecauses:patientsbeingseenintwoormoreclinicsonthesameday,chartsnotbeingforwarded,physicianskeepingrecordsintheirofficesorremovingthemfromtheiroffices,andrecordsbeingmisfiledinthefileroom.OnehospitalintheGAOstudyonautomatedmedicalrecordsreportedthatitcouldnotlocatemedicalrecords30percentofthetime(GAO,1991).Evenwhenrecordsarereadilyavailable,theamountoftimerequiredtoretrievenecessaryinformationfromarecordcanfrustrateusers(Fries,1974;Zimmerman,1978;Pories,1990).Forresearchers,accesstopaperrecordscanbeproblematicandisgenerallyresourceintensive(Davies,1990).Identifyingrecordsthatcontainneededdata,retrievingneededrecords,reviewingrecords,collectingdata,andenteringdataintodatasetsforanalysisaretime-consuming,expensivetasks.Yetaccesstoexistingcomputer-basedrecordscanalsoprovedifficultforresearchersbecausedocumentationonhowtousesystemsmaybelacking.Further,dataaggregationcanbehamperedbylackofcompatibilityamongsystems.BeyondTechnologyMeetingthechallengeofmanaginghealthcareinformationdependsonmorethantechnologicaladvances.Theusefulnessofanytechnologydependsonhowwellitanditsprogenyareapplied.Inadditiontotechnology,astudyoftheimprovementofpatientrecordsmustaddresshowtheuseofthoserecordsmightbeimproved,aquestionthatraisespotentiallysensitiveissues.15"Improvingrecords"and"improvingclinicalreasoning"aretopicsinevitablyconnectedtooneanotherbecauseideallytherecordreflectstheclinicalreasoningprocess.Ifbetterrecordsystemsaretobecreatedinthefuture,theusermustberecognizedaspartofthesystem,andtheproblemsolvingactivitiesofpractitionersmustbeexamined.Inadditiontotechnologicalandbehavioralopportunitiesforimprovingpatientrecords,certainstrategicissuesmustbeaddressed.Otherinformation-intensiveindustries(e.g.,banking)havesuccessfullyimplementedwidespreadcomputer-basedinformationmanagementtechnologies.Understandingthefactorsthathaveslowedthedevelopmentanddiffusionofsuchtechnologiesinhealthcareisafirststeptowardachievingmorerapidadvancesinthefuture.WhyNow?Manyattemptshavebeenmadeovertheyearstoadvanceclinicalcomputing,toreformthepatientrecord,andtoencouragehealthcareprofessionalstomaintaintherecordmoreconscientiously(e.g.,byenteringnecessaryclinicaldata).Whyshouldorhowcouldrenewedeffortstoestablishtheroutineuseofnewcomputer-basedrecordsystemssucceednowwhenpreviousattemptshavefailed?Whymightthisreporthaveasignificantimpact?Thecommitteebelievesthatfiveconditionsoftheenvironmentinwhichitsstrategicplanmightbeimplementedincreasethelikelihoodofachievingwidespreaduseofcomputer-basedpatientrecords.First,currentdemandsforpatientinformationthroughoutthehealthcaresectorwillnotdiminish;indeed,theywillprobablyincrease.Second,technologiesessentialtocomputer-basedpatientrecordsarebecomingmorepowerfulandlessexpensiveExaminationoftheroleofpatientrecordsintheclinicalprocess,asmanifestedinthedebatesurroundingtheproblem-orientedrecord,hasbeenunderwayformorethan20years(Weed,1968;Goldfinger,1972;Margolis,1979).SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.×AddanotetoyourbookmarkThird,patientsandpractitionersgraduallyarebecomingaccustomedtotheuseofcomputersinvirtuallyallfacetsofeverydaylife.Fourth,anagingandmobilepopulationresultsinmoreinformationtobemanagedanddemandsforimprovedtransferabilityorportabilityofthatinformation.Finally,thecommitteebelievesthatthosecomponentsofneededreforminhealthcarethatrequireevaluation,consolidationofdata,andimprovedcommunicationwillnoteasilybeachievedwithoutreformsinthescope,use,andautomationofthepatientrecord.

附录B.外文翻译-译文部分基于计算机的患者记录：医疗保健的基本技术简介:患者记录是有关患者健康护理信息的主要存储库。它在某种程度上影响了与提供，接受或报销医疗保健服务相关的几乎所有人。尽管过去几十年在医疗保健方面取得了许多技术进步，但今天的典型患者记录与50年前的患者记录非常相似。由于从业人员，1名患者，管理人员，第三方付款人，研究人员和政策制定者的信息需求经常无法满足，因此患者记录的这种失败现在正在已经负担沉重的美国医疗保健系统中产生额外的压力。如Ellwood（1988：1550）所述：我们的医疗保健系统错综复杂的机制再也无法掌握经验的线索，付款人，医生和医疗保健管理人员往往不会对患者的生活有共同的见解。医疗保健系统已经成为一个由错误的选择;它不稳定，困惑，迫切需要一个中枢神经系统，可以帮助它应对现代医学的复杂性。患者记录的改善可以为改善这个国家的医疗保健系统做出重大贡献。1991年美国总审计局（GAO）关于自动医疗记录的报告确定了改善患者记录可以使医疗保健受益的三种主要方式，委员会使用术语从业者来指代为患者提供临床服务的所有医疗保健专业人员。这些专业人员包括但不限于医生，护士，牙医和治疗师。首先，自动化患者记录可以通过为医务人员提供更好的数据访问，更快的数据检索，更高质量的数据以及更多的数据显示功能来改善医疗保健服务。自动化患者记录还可以支持决策制定和质量保证活动，并提供临床提醒以协助患者护理。其次，自动化患者记录可以通过电子捕获临床信息进行评估来增强结果研究计划。第三，自动化患者记录可以通过降低成本和提高员工生产率来提高医院效率。有几个来源支持这些结论。GAO报告称，由于住院时间缩短，自动医疗记录系统使退伍军人事务部医院的每名患者的住院费用减少了600美元（GAO，1991）。在计算机化医疗记录和医疗记录摘要的其他研究中也发现了住院时间的减少（Rogers和Haring，1979）。其他研究人员发现，加强护理并改善临床患者的护理结果（Rogers等，1982）和减少用药错误（Garrett等，1986）。提高患者记录的第一步是仔细检查患者记录的用户，可用于创建和维护患者记录的技术，以及增强患者记录的障碍。为此，美国国家科学院医学研究所（IOM）开展了一项研究，建议改进患者记录，以响应不断扩大的功能要求和技术进步。纸质病患者记录的优点和缺点委员会的文献综述没有透露任何关于纸质病历记录优势的实质性文件。这个结果可能是医疗保健专业人员可以保留单独的患者记录以保护敏感数据（例如，精神病史）或支持研究兴趣（即，包含研究项目的详细数据的单独记录）。药房捕获与患者护理相关的信息，但不保留完整的患者记录。有关所开药物的信息和编写处方的医生的专业知识可以提供足够的信息来确定患者的医疗问题，然而，药房记录可能因此提出类似于与患者记录相关的机密性问题。由于委员会更密切关注传统的患者护理记录，因此本报告未涉及与药房记录相关的问题。部分地通过以下事实解释了维护患者记录的价值在医疗保健界被广泛接受，并且该纸是最广泛使用的记录保存形式。鉴于纸质病历记录普遍存在，委员会指出，不应低估从业人员对这种记录保存的支持。时间和资源限制不允许委员会调查用户对纸质记录的态度;但是，委员会成员从记录用户的角度确定了至少五种这类记录的优势：纸质记录对于那些因此不需要获得新技能或行为的用户来说是熟悉的。纸质记录是便携式的，可以带到护理点。一旦掌握，纸质记录就不像计算机系统那样经历停机。纸质记录允许记录数据的灵活性，并且能够容易地记录“软”（即主观）数据。可以浏览和扫描纸质记录（如果它们不是太大）。此功能允许用户以各种方式组织数据，并查找未明确说明的模式或趋势。对当前患者记录的批评有时是尖锐的。Burnum（1989：484）指出，“长期存在错误的医疗记录包含比以往更多的扭曲，删除和误导性信息。”Pories（1990：47）讲述了一位工程师的故事，该工程师被要求建议更有效地使用医疗保健人员，但却“被医疗记录的混乱和医疗服务的低效率所震惊”。工程师得出结论：“重新设计记录为医疗成本控制和预防医疗事故提供了最直接，最简单的方法”保守党认为，这种情况没有改善，也没有孤立。“没有人对这个问题有垄断地位：整个土地上的医疗记录似乎同样危险和危险”（Pories1990：47）。在他看来，患者记录往往缺乏最有益的使用所需的功能，他并不孤单。在最近对学术和私人实践中的内科医生进行的一项调查中，63％的受访者同意这样的说法：患者记录在不改善患者护理质量的情况下变得越来越繁重（Hershey等，1989）。如文献和委员会的工作所述，患者记录的弱点可归入四个主要标题：（1）内容（2）格式（3）访问，可用性和检索（4）联系和整合。患者记录内容的问题。患者记录数据经常缺失，难以辨认或不准确（Tufo和Speidel，1971;Zuckerman等，1975;Bentsen，1976;Zimmerman，1978;Fox等，1979;Romm和Putnam，1981;Gerbert和Hargreaves，1986;Hsia等，1988;Pories，1990）。数据可能缺失至少有三个原因：（1）从未问过问题，从未进行过考试，或者从未订购过测试;（2）要求并提供信息，但临床医生没有记录信息，或者将信息记录在记录中发生了延误;（3）信息被要求和交付但是错放或遗失。此外，临床医生，患者或设备都可能在患者记录中引入错误（Burnum，1989）。许多研究已经检查了患者记录内容的质量。表1-1列出了几项此类调查的结果。各种研究中报告的缺失信息经常导致患者护理的额外费用。例如，在一家医院中估计有11％的实验室检查被要求重复检查，在患者就诊时医生无法获得这些检查结果（Tufo和Speidel，1971）。虽然有些记录缺少数据，但在其他情况下，某些数据过多或过多（Zimmerman，1