电子病历实施中的问题与对策

以现代化病案管理模式为基础,阐述电子病历实施过程中遇到的一些问题,如信息标准不统一而阻碍电子病历的推广、法律地位及法律性质不确定导致在诉讼中不能作为直接证据、给患者隐私权带来威胁等。以电子病历的稳步发展为导向,提出了解决问题的若干对策,包括制定统一的信息标准规范电子病历、出台相关法律法规、提高技术手段确保电子病历的合法性和安全性。

The Problems and Countermeasures During Implement of Electronic Medical Records

At the basis of modernization medical records management mode,this paper elaborates some problems during implement of electronic medical records,such as nonunity information standard hindering the popularization of electronic medical records,not being taken as direct evident for non-determinate legal status and legal nature in lawsuit and bring threatening for patient’s privacy and etc.As the guidance of steady development of electronic medical records,it puts forward some countermeasures for solving problems,including establishment of unity information standard for standardizing electronic medical records,related laws and regulations unveiling,improvement of technique means for making sure legitimacy and safety of electronic medical records.