Preparing physicians for a computer-based patient record system

The Providence experience provides a model which encompasses both preparation for a computer-based patient record and a physician-oriented approach to achieving quality documentation for the physician component of the patient record. The study comparing Providence to a similar medical center demonstrated the value of the new system in achieving quality patient records. Many hospitals in the Seattle area, including Overlake, now use this system or variations of it.     

A computer-based patient record: Emory's approach

The replacement of the paper medical record at Emory will be gradual over the next several years. We foresee milestone events after which portions of the patient record are no longer retained in paper form. As these milestones are identified, the HIM professionals at the three institutions will begin the formidable task of managing the transition to a paperless system. Evaluation of business processes and the skill sets needed by staff members can be accomplished and a plan for each phase of transition developed.     

The state of the computer-based patient record

Value, experiments, promises, disappointments, hype, compromises, and change all characterize the status of the computer-based patient record (CPR). An industry expert offers some perspective on where the CPR has been and where it's going.     

电子病历的安全控制

电子病历是病历的发展方向，但目前存在法律地位确立和社会认可问题。究其原因是没有很好解决电子病历的安全性、隐私保密性及不可否认性，本文根据医院信息系统存在的问题，提出指纹认证、“用户／岗位角色／功能权限”三级权限控制策略等全面系统解决方法，使电子病历具有真宴、完整、保密和不可否认性，足进其全面发展。     

An investigation of barriers to computer-based patient record implementation

A study was conducted to verify barriers to implementing computer-based patient record systems as perceived by a random sample of members of the American Health Information Management Association, the American Medical Informatics Association, and the Health Information Management and Systems Society. Study respondents were asked to identify the likelihood of their institution overcoming the barriers and which, if any, strategies would be most helpful in overcoming them. This article discusses the study results.     

全程电子病历质量管理的实施

目的随着CPR应用的不断深入，其管理和使用过程中的有关问题逐步暴露出来，如何确保CPR信息准确、安全，保持其原始性、真实性，是电子病历开发、使用者和医院管理者高度重视的课题。在电子病力使用过程中存在的主要问题是程序和电子病历模板设计不完善、智能化程度低、病历内涵和外在质量问题较多(病历的客观真实性受到挑战，病历内容的雷同化现象，存在严重的质量缺陷，病案首页信息不规范，打印质量问题，His网上数据欠准确)、保密设置功能不完善、医一护之间的脱节现象、病历的存储和流通格式有待规范。方法为此需要采取如下措施：不断完善电子病历源程序；建立智能化平台；建立网络模式下新的病案监控手段和管理方式、加强HIS网上数据监控、开发电子病历质量监控软件、健全电子病历的安全防范措施等。结果电子病历质量明显提高。