提高电子病历规范化应用水平——电子病历及其应用概述

电子病历（EMR）指医疗机构采集和保存的个人健康资料的数字化记录。EMR的实施需要在医疗机构内建立基于计算机和信息网络的个人电子健康信息储存和检索系统，实现以患者为中心的数据集成和访问。通过EMR系统与临床决策支持工具的整合，EMR可成为促进循证医疗、改善医疗质量的有力工具；通过提供完整、准确的临床数据，EMR也是医疗质量评价和持续改进的必要手段；在EMR基础上构建的、可以跨机构、跨时段、跨地域共享的电子健康记录（EHR）支持区域协同的医疗服务新模式，是提高医疗资源利用效率、改善卫生服务体系整体绩效的有效途径。EMR／EHR的实现在技术上依赖信息的标准化和信息系统的互操作性，也受法律、制度、政策、资金、观念等环境因素的制约。

Overview of Electronic Medical Record and Its Application

Electronic health record （EMR） is digital record of a person＇s health data collected and held by health providers. The application of EMR is to build a health information storage and retrieval system in an organization based on computer network for patient - centric data integration and browse. By combination of EMR system and clinical decision support tools, EMR can promote evidence - based practice and quality health care. EMR can also function as an essential tool to evaluate and improve the quality of heahheare by providing comprehensive and accurate clinical data. Electronic Health Record （ EHR）, which is based on EMR and enabling information sharing across different health providers, systems and regions, supports continues and coordinated healthcare for a patient involved different organizations within a region, advancing cost - effective care and the performance of the whole health service system. The implementation of EMR/EHR depends on the interoperability of information systems and needs non- technical environment supports such as policy, financial, euhural environment.