电子病历系统核心功能的确定

发布时间：2022-12-05 04:59:28


Paper-basedrecordshavebeeninexistenceforcenturiesandtheirgradualreplacementbycomputer-basedrecordshasbeenslowlyunderwayforovertwentyyearsinwesternhealthcaresystems.Computerizedinformationsystemshavenotachievedthesamedegreeofpenetrationinhealthcareasthatseeninothersectorssuchasfinance,transportandthemanufacturingandretailindustries.Electronicmedicalrecordsystemslieatthecenterofanycomputerizedhealthinformationsystem.Withoutthemothermoderntechnologiessuchasdecisionsupportsystemscannotbeeffectivelyintegratedintoroutineclinicalworkflow.The2003IOMpatientsafetyreportdescribesanEMRasencompassing:"alongitudinalcollectionofelectronichealthinformationforandaboutpersons[immediate]electronicaccesstoperson-andpopulation-levelinformationbyauthorizedusers;provisionofknowledgeanddecision-supportsystems[thatenhancethequality,safety,andefficiencyofpatientcare]andsupportforefficientprocessesforhealthcaredelivery."[IOM,2003,P4(footnote].TheUSIOMreport,KeyCapabilitiesofanElectronicMedicalRecordSystem[Tang,2003],identifiedasetof8corecaredeliveryfunctionsthatelectronichealthrecordsystemsshouldbecapableofperforminginordertopromotegreatersafety,qualityandefficiencyinhealthcaredelivery.Theyare:Healthinformationanddata:Havingimmediateaccesstokeyinformation-suchaspatients'diagnoses,allergies,labtestresults,andmedications-wouldimprovecaregivers'abilitytomakesoundclinicaldecisionsinatimelymanner.


Resultmanagement:Theabilityforallprovidersparticipatinginthecareofapatientinmultiplesettingstoquicklyaccessnewandpasttestresultswouldincreasepatientsafetyandtheeffectivenessofcare.
Ordermanagement:Theabilitytoenterandstoreordersforprescriptions,tests,andotherservicesinacomputer-basedsystemshouldenhancelegibility,reduceduplication,andimprovethespeedwithwhichordersareexecuted.
Decisionsupport:Usingreminders,prompts,andalerts,computerizeddecision-supportsystemswouldhelpimprovecompliancewithbestclinicalpractices,ensureregularscreeningsandotherpreventivepractices,identifypossibledruginteractions,andfacilitatediagnosesandtreatments.
Electroniccommunicationandconnectivity:Efficient,secure,andreadilyaccessiblecommunicationamongprovidersandpatientswouldimprovethecontinuityofcare,increasethetimelinessofdiagnosesandtreatments,andreducethefrequencyofadverseevents.
Patientsupport:Toolsthatgivepatientsaccesstotheirhealthrecords,provideinteractivepatienteducation,andhelpthemcarryouthome-monitoringandself-testingcanimprovecontrolofchronicconditions,suchasdiabetes.
Administrativeprocesses:Computerizedadministrativetools,suchasschedulingsystems,wouldgreatlyimprovehospitals'andclinics'efficiencyandprovidemoretimelyservicetopatients.

电子病历系统核心功能的确定

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