Electronic Medical Record (EMR, Electronic Medical Record) is also known as computerized medical record system or computer-based patient record (CPR, Computer-Based Patient Record). It is a digitized patient's medical record that is saved, managed, transmitted and reproduced using electronic devices (computers, health cards, etc.), replacing the handwritten paper medical record. Its content includes all the information of a paper medical record. The National Institute of Medicine defines an EMR as an electronic patient record based on a specific system that provides users with access to complete and accurate data, alerts, reminders, and clinical decision support systems.
The patient record is the original record of the entire process of diagnosis and treatment of the patient in the hospital, which contains the first page, the record of the course of the disease, the results of the examination and testing, the doctor's orders, the surgical record, the nursing record, and so on. The electronic medical record not only refers to the static medical record information, but also includes the provision of related services. It is electronically managed information about an individual's lifelong health status and healthcare behaviors, involving the collection, storage, transmission, processing, and utilization of patient information for all process information.
The electronic medical record is generated with the networked computer management in hospitals, the application of information storage media - CD-ROMs and IC cards, etc. and the globalization of the Internet. Electronic medical records is the inevitable product of information technology and network technology in the medical field, is the inevitable trend of the modern management of hospital medical records, its initial application in the clinic, greatly improving the efficiency of the hospital and the quality of medical care, but this is still only the beginning of the application of electronic medical records.
What exactly is the electronic medical record, the academic community still lacks a unified understanding. According to current research, the ideal electronic medical records should have two functions:
1, doctors, patients or other authorized people, in need of any health data or related information about an individual, in any case can be complete, accurate, timely access to them, and can be accurately interpreted, in the need to maximize access to detailed, accurate, and comprehensive relevant knowledge.
2, the electronic medical record can be based on their own information and knowledge, take the initiative to make judgments, in the individual health state needs to be adjusted, to make timely and accurate tips, and give the optimal program and implementation plan. The reason why it is called an ideal electronic medical record is because these two aspects of the function seems to be simple, but the meaning is profound, and it is difficult to fully realize in decades. After the introduction of the concept of electronic medical records, the current use of paper medical records are generally referred to as the traditional medical records, it is the main difference between the electronic medical records are as follows:
1, the traditional medical records are passive, static, isolated, electronic medical records are active, dynamic, associated with the traditional medical records do not have the second aspect of the function of the electronic medical records, i.e., there is no initiative and intelligence, and can not be associated with the relevant knowledge. Paper medical records are placed there, can be read, can also add new content, but its content and content can not establish an organic link between the content of the medical record and the actual state of the patient is completely out of touch with the content of the medical record and its related knowledge is not connected, the medical record can only complete the order of the unchanged role of the record. The revolutionary difference of electronic medical records lies in the fact that the information stored in them is no longer isolated and static, but related and dynamic, and is no longer just a block of information, but a collection of knowledge. The newly added information will establish the necessary connections with all the information that already exists, transforming the structure, analyzing and judging the patient's status in a comprehensive manner based on the existing knowledge, laws, rules, and precedents, proactively prompting the relevant doctors or patients; proposing examination and treatment plans, etc. For example: an electronic medical record system for managing kidney dialysis can record all the relevant physiological indexes of the patient and all the previous dialysis conditions and other information, which have been processed and organized when entering the system. When a patient completes a dialysis treatment, the system will immediately put forward a set of detailed treatment plans for the next stage or relevant recommendations, including whether additional examination items are needed or not, based on the immediate detection of the instrument and the new examination results inputted by the doctor, and integrating the previous conditions. The system will immediately propose a detailed set of next stage treatment plan or related recommendations, including whether additional examination items are needed, whether auxiliary medication is needed, the measurement of medication, etc.. After the doctor gives his/her own plan with reference to the plan provided by the system, the EHR system will make judgment based on its stored knowledge, and alert the doctor if it finds any contradiction or inconsistency with the general rule or violation of special principles. The doctor can ask what are the contradictions, their principles and literature. If the doctor sticks to his or her plan, implements it, and it ultimately proves to be effective, the EHR system learns the plan and keeps it as a precedent. This example shows that the recording function of the traditional medical record in the electronic medical record is only one aspect of many functions.
2, the traditional medical records can not guarantee the integrity of the data, electronic medical records can ensure complete, accurate, timely access to information.
This flaw in the traditional medical record stems from a number of aspects.
First of all, the development of inspection, treatment, monitoring and other technologies, even including the development of management technology are negating the traditional medical records. According to the original intention of case management, all patient-related information should finally be concentrated in the case for unified storage. x-ray film was the first to be separated from the case and separate management, pathology slides, smears are never included in the case, CT, B ultrasound, MRI, and other imaging imaging examination, perioperative monitoring, dialysis treatment, rehabilitation and so on, all kinds of checking and treatment of a large number of information are saved outside the case, the case of only a brief report into the case. The case is only a short report or part of the brief image data, some of them in addition to the doctor's orders and medical log or even what specific information has not been left in the case, the information is scattered in the custody of the various professional departments or be discarded.
On the other hand, due to the limitations of traditional medical records on paper, even if some information, such as a section of Doppler ultrasound video, wish to be kept together with the case, it is not possible. After the information system was put into use, information such as medical advice was deposited into the computer, and although there were still printed pages bound into the case, fewer and fewer people viewed the information on paper. Taken together, it is not difficult to see from the general trend that the proportion of total patient information kept through the case is rapidly becoming smaller, and in a not too distant future, the paper medical record will inevitably lose its meaning of existence.
Second, the development of transportation, so that people's concept of region weakened. The reform of the medical system allows patients to choose multiple hospitals to visit. A person can see a different hospital in Beijing's east or west city, and may also see a hospital in Shenzhen or Xi'an. With the use of paper medical records, it is very difficult for any one hospital to get a full picture of other hospitals' medical records on a particular patient. This difficulty is not limited to the form, the results of different hospitals, idioms, quality control standards, etc., other hospital doctors basically have no way to know.
The electronic medical record can comprehensively manage all kinds of information.
Can be centralized management, can also be decentralized management and theoretically collect a complete variety of decentralized management information. For example, a patient to do CT examination, he was doing the examination, radiology doctors can instantly see its image, the doctor in charge of the electronic medical record system in the ward at the same time to watch, but at this time due to radiologists have not given a diagnosis report, the relevant image information is mainly kept in the radiology department. When the diagnosis is made, the relevant information through the computer network is automatically transmitted to the electronic medical records room for permanent preservation, at this time, the doctor in charge can only appreciate the difference in content, where the specific information is located, do not need to care. Different hospitals electronic medical records can be completed through the network and the necessary protocols, standards in the exchange of data transmission between hospitals, doctors can get comprehensive information, the same is not to care about the location of the medical records.
3, the traditional medical records can not get the necessary interpretation, can not be associated with knowledge
The so-called interpretation, is to explain the meaning. For the case, interpretation includes two aspects:
First, different hospitals, different doctors or staff use the terminology or check the information recorded on the instrument, the actual meaning of which needs to be explained, so that different people can be correctly informed of its precise meaning. For example, a case from one hospital needs to be interpreted when it is read in another hospital. The need for interpretation is even greater when the medical record is read by non-medical personnel such as patients or insurance company personnel.
Second, for the rusty terminology or new concepts or new tests, treatment programs, new drugs, and so on, due to specialization, qualifications, or new advances, it is necessary to explain the theoretical basis, meaning, normal values, indications, and so on. The interpretation function requires the use of artificial intelligence technology, especially knowledge engineering. Knowledge correlation is important for medical interns, trainees and junior doctors. Knowledge association is also conducive to solving the difficulty of reading medical records due to the specialization, and facilitates the application of medical records of high-level hospitals for doctors in low-level hospitals***. This type of functionality is not available in paper medical records at all.
4, the traditional medical records can not guarantee timely access, can not *** enjoy
In addition to the aforementioned cases belonging to different hospitals and the inconvenience caused by access, the same hospital will also be due to the case is being borrowed, not yet filed, lost, and other reasons for the cause of the medical records can not be in place in a timely manner. The use of electronic medical records can completely change this situation, a patient's medical records can not only be accessed by many people at the same time, but also can be off-site, different hospitals to get. If access to the wireless network, the doctor can at any time, such as on the road or in the meeting, access to medical records.
The above describes some of the main differences between an ideal electronic medical record and a traditional paper medical record. However, the current reality of the electronic medical record, for a variety of reasons, is less than ideal. The concept of the reality of the electronic medical record is a concept of development, the concept of change, or electronic medical records have many versions of reality. The current widely accepted definition of an electronic patient record was proposed by the Institute of Medicine (IOM) in 1991, as follows:
"......an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other
"an electronic patient record that resides in a system specifically designed to support users through availability of complete and accurate data, practitioner reminders and alerts, clinical decision support systems, links to bodies of medical knowledge and other aids. decision support systems; connections to medical knowledge sources; and other assistance.
This definition refers to a concept called an electronic medical record system.
Traditional medical records require healthcare professionals to record information with the help of paper and ink, and a group of professionals to manually process, organize, and maintain the records. A medical record is usually a stack of paper with information on it.
Electronic medical records need to be transformed into interactive information form with the help of computer equipment, combined with data acquisition, recording, processing, storage, management, transmission and other work to complete the electronic medical records function. These tasks are completed through a set of computer systems, this system is the electronic medical record system. Electronic medical record system is electronic medical records dependent on the existence of a computer system, electronic medical records is the electronic medical record system function form or function of the general term. As compared to the "system" concept, health care workers are more concerned about the content of the medical record, and are willing to be specific, visualization, so usually fuzzy use of the concept of electronic medical record system, whether it is a "system" or the electronic medical record itself, are generally referred to as the electronic medical record.
In the literature on electronic medical records, there is a word called virtual medical record (VMR Virtual Medical Record). This term helps to understand the electronic medical record.
The so-called virtual medical record refers to a computer system that manages a sufficient amount and type of medical record information, and when needed, can completely reproduce the entire content of the paper medical record, but its data preservation is not confined to the traditional form of medical records. It is important to note that the virtual medical record emphasizes the ability of computerized medical record data to reproduce the traditional medical record from form to content. For electronic medical records, it is perfectly possible to reproduce the content and form of traditional medical records, but electronic medical records are not bound to reproduce, nor do they seek to reproduce, but rather to pursue a more rational and efficient form. This is the use of virtual medical records and electronic medical records concepts need to pay attention to.
Application status:Over the past 20 years, some large hospitals in Europe and the United States began to establish the hospital information system (HIS) within the hospital, and consequently the electronic medical record in the United States, the United Kingdom, the Netherlands, Japan, Hong Kong and other regions have a considerable degree of research and application. The U.S. government has been vigorously promote and popularize the application of EMR, Indiana University School of Medicine to use EMR to predict the mortality rate of patients with early-stage cancer, the Boston EMR Association is studying the transmission of emergency patients through the Internet EMR issues. The United Kingdom has applied the IC card of EMR to pregnant women for pregnancy information, labor revelation and follow-up observation. Hong Kong Hospital Authority's Patient Card (Patient Card) records the patient's complete medical process, including doctor's examination, test results, X-rays, CT films MTI films and prescriptions. At the same time, these countries and regions have set up special research institutions to study EMR as a key topic, and organize medical units to implement and popularize it.
After nearly 20 years of development, China's hospital information system has begun to take shape, many hospitals have set up hospital-wide information systems, represented by the Huiyuan Hospital Management Information System of Dalian Huiyuan Electronic System Engineering Co. The Golden Guardian Card supervised by the State Ministry of Health will be launched to the whole society, which can save the cardholder's lifelong healthcare information, and the cardholder can be directly networked with banks, medical insurance centers and insurance agencies through computer networks, making medical activities simple, convenient and fast. The General Hospital of the People's Liberation Army (PLA) has carried out EMR research and application. This is only the beginning of EMR research and application, related research content will be with the development of EMR and in-depth
Relationship with the HIS: 1, the electronic medical record is dependent on the HIS. electronic medical record system is not a new system independent of the HIS, because the patient's information comes from the HIS in the various business subsystems. For example: the first page of the case comes from the hospitalization registration, in and out of the transfer, case cataloging and other systems. While each business system accomplishes its own functions and manages its own business data, it also collects patient information. Therefore, separated from the HIS, there is no electronic medical record system. It can be said that electronic medical records permeate the HIS.
2, the electronic medical record system and the traditional HIS is different. From the point of view of the electronic medical record patient information, is complete, integrated; and from the traditional HIS of each subsystem to see the patient information, is localized, discrete, redundant information between each other, there are omissions, they are often not in accordance with a unified principle of design and management. In terms of content, there are different focuses and requirements. For example: to statistics and retrieval for the purpose of case home management of the patient's diagnosis as long as the entry to save the ICD code can be, and from the perspective of the electronic medical record must be complete to retain the doctor's diagnostic description of the diagnostic description and the ICD classification code can not be replaced by each other. The electronic medical record emphasizes the originality and completeness of patient information.
The electronic medical record is with the hospital computer management network, information storage media - CD-ROM and IC card and other applications and the globalization of the Internet and the emergence of. Electronic medical records is the inevitable product of information technology and network technology in the medical field, is the inevitable trend of modernization and management of hospital medical records, its initial application in the clinic, greatly improving the efficiency of the hospital and the quality of medical care, but this is still only the beginning of the application of electronic medical records.
Advantages:1, fast transmission speed. Medical staff through the computer network can remotely access the patient's medical records, in a few minutes or even seconds to the data can be transmitted to the place where it is needed. In an emergency, the information in the electronic medical record can be promptly checked and displayed in front of the physician.
2, **** good enjoyment. Now the use of conventional medical records have a great deal of closure. Hospitals diagnosis and treatment of patient records are only saved in the hospital, if the patient to other hospitals need to re-examine, which not only wastes valuable medical resources but also makes the patient increase a lot of necessary pain. The use of electronic medical records can overcome these shortcomings. The patient's diagnosis and treatment results in each hospital can be transmitted through the computer network between hospitals or the health card (optical card and IC card) that the patient carries with him. The *** enjoyment of medical records will bring great convenience to medical treatment.
3, storage capacity. Because of the computer storage technology, especially the progress of optical disk technology, electronic medical record system database storage capacity can be quite huge, and the patient carries a health card (optical card or IC card), its capacity is also considerable.
4, easy to use. Medical staff using the electronic medical record system can easily store, retrieve and browse the medical records, copying is also very convenient, can be convenient, rapid and accurate to carry out a variety of scientific research and statistical analysis, greatly reducing the workload of manual data collection and entry, greatly improving the level of clinical research.
5, low cost. Electronic medical record system after a one-time investment in the completion of the use of the patient's costs and hospital expenses can be reduced. At present, there are some shortcomings of electronic medical records. For example, the need for a large number of computer hardware and software investment and personnel training, some medical personnel are even difficult to adapt to computer operation. Once the computer fails, it will cause the system to stop and not be able to work, therefore, it is often necessary to save the original records manually. There are also various errors (mainly operational errors) that often occur when entering medical record data into the computer, which require strict checks to prevent errors and accidents.
Main Features:
1. Structured storage
2. Medical record template library
3. Required item checking
4. Support for a variety of medically-specific expressions (e.g., formulaic expressions for menstrual history, fetal heart, and caries location).
5, support for medical records document three-level inspection (three-level review) function
6, support for the retention of traces of modification, to retain the traces of modification of doctors at all levels
7, the time control mechanism, the use of the main push mode of the workflow, the task of the automatic prompts, timely reminder and urging the medical staff to complete the work of the medical record on time, according to the quality of medical records written in accordance with the quantity to avoid the lack of medical records, writing, omission, delayed writing, and the effective medical record documents. The system can also be used as a stand-alone system to provide a more efficient and effective way to manage and monitor the workflow of the medical staff.
8, support for data element binding, the realization of the multi-document synchronization refresh technology
9, form processing capabilities (you can easily create a form of medical records), support for form nesting, merging cells, split cells, delete rows, delete columns, add rows, add columns, insert elements in the form, form width manual or automatic adjustment
10, support for the entry of values Legitimacy check
Electronic medical records as the core of the clinical information system: electronic medical records is the core of the medical information system in the hospital. The main function of the medical information system is to provide information services for the hospital's medical treatment, and all its functions are based on the processing of the patient's medical record information. It includes:
① patient's name, gender and other natural information.
② The patient's admission, discharge, transfer, transfer and other popular conditions.
③ Records of various examinations the patient received in the hospital.
④ Records of various treatments performed by physicians for patients.
⑤ Records of nursing care for the patient.
With a medical information system centered on electronic medical records, the process of medical work will change dramatically. If an emergency patient suddenly came to the hospital, the physician can bring the patient's health card inserted into the computer, so that the computer will immediately show the patient's situation, such as name, age, drug sensitivity, etc., at this time, the physician will be able to open according to the patient's clinical manifestations of the need for examination project list. After completing the examination, the treating physician can immediately get the examination results and make diagnosis and treatment opinions. If it is a difficult case, the attending physician can also through the computer network system to ask a superior physician or specialist for consultation. The supervising physician or specialist can provide consultation opinions in his office or at home to help the treating physician to make treatment plans. The application of electronic medical records and computer information systems will make this medical consultation time is greatly reduced, the quality is greatly improved.
Foreign in 1994 launched a multimedia electronic medical records record system - Viewscope, is a representative of the electronic medical records as the core of the hospital information system. The system is a set of images, video, audio and text in one of the multimedia micro-computer system, it can be from a variety of data sources at the same time access to information, so that medical personnel can be from an ordinary desktop microcomputer system to access all the patient's records, such as X-ray and ultrasound images, watch the condition of the record of video and audio recordings, etc. Viewscope system in the information stored in the system includes. The information stored on the Viewscope system includes:
① Computed tomography (CT or CAT) scans, MR*** vibration images, X-rays, ultrasound images, and photographs;
② Documents such as charts, graphs, letters, and receipts;
③ Video recordings made during surgeries;
④ Medical reports and audio recordings interpreting the X-ray films.
Multi-media electronic systems can be used to access all of a patient's medical records at one time, such as X-ray and ultrasound images, to view video recordings of medical conditions, and to record audio recordings of medical conditions.
Viewscope, a multimedia electronic medical record system, can also be linked to other medical information systems to form a hospital information system with an electronic medical record at its core.