Electronic Medical Record (EMR, Electronic Medical Record), 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 medical record is the original record of the patient's diagnosis and treatment in the hospital, which contains the first page, the record of the course of the disease, the examination and test results, the doctor's orders, surgical records, nursing records and so on. 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, which involves the collection, storage, transmission, processing, and utilization of all process information of patient information.
Electronic medical record is with the hospital computer management network, the application of information storage media - CD-ROM and IC card, etc. and the globalization of the Internet and the emergence. 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, and 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. The widely accepted definition of 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 information. links to bodies of medical knowledge and other aids.
The translation is along the lines of:
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; Connection to medical knowledge sources; and other assistance. 1. Safe and Reliable
The safety and value of EMR can be ensured through the implementation of EMR hierarchical confidentiality management, and the establishment of hierarchical authorization for accessing, inputting, modifying and using EMR. At the same time, the system provides data backup and recovery tools. The establishment of a data backup system at workstations at all levels can ensure maximum recovery of data in case of damage.
2. Storage, easy access
EMR will not mold, deterioration, and heat resistance, corrosion resistance, storage convenience. EMR does not require a huge storage space. Medical staff in their own computer terminals can find case information, but also can be entrusted to the data center to find, print, direct transmission or copy transmission information. Outside users are authorized to query the data center through the Internet for relevant case information.
3. Strong timeliness
Patients can authorize doctors to access their EMR when they seek medical treatment, assisting medical staff to quickly, intuitively and accurately understand the patient's previous treatment and examination of accurate information, avoiding errors and omissions in the patient's medical history due to unclear memory, shortening the doctor's diagnosis of the time to save lives and win valuable time. As early as 2010, the national hospital after government procurement of electronic medical records construction and implementation projects, the actual contracted amount of software has reached between 100 million to 150 million yuan; in 2011, the total market for electronic medical records software rose to 150 million to 250 million yuan, and today's market size, although expanding, but with more and more participants, resulting in increasingly fierce competition.
Currently, leading domestic companies such as EaseUS electronic medical records, due to its strong R & D strength and high degree of specialization, in the field of hospital information system R & D advantages. Over the past 20 years, some large hospitals in Europe and the United States have begun to establish hospital information systems (HIS) within the hospital, and consequently, electronic medical records have been researched and applied to a considerable extent in the United States, the United Kingdom, the Netherlands, Japan, Hong Kong and other regions. 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, and many hospitals have successively established hospital-wide information systems, as 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, and the related research content will be deepened with the development of EMR.
With the increasing popularization of computer technology application, the term electronic medical record began to appear in hospital management and medical work. However, many healthcare workers are still rusty on the concept of electronic medical records. Some people have heard of this term, but the understanding is not precise or have doubts. In this article, we would like to provide a brief common sense introduction to the concept of electronic medical records. The academic community still lacks a unified understanding of what exactly an electronic medical record is. According to the study, the ideal electronic medical record should have two functions:
1. Doctors, patients or other authorized persons, 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 knowledge.
2. The electronic medical record can take the initiative to make judgments based on the information and knowledge it possesses, make timely and accurate prompts and give the optimal program and implementation plan when the individual's health status needs to be adjusted. The reason why it is called an ideal electronic medical record is because these two functions seem to be simple, but the meaning is profound, and it will be difficult to fully realize it within a few 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, which is the main difference between the electronic medical records are as follows:
1. 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, that is, 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 information, which have been processed and sorted out when entering the system. When a certain patient completes a dialysis treatment, the system will, according to the immediate detection of the instrument and the new examination results inputted by the doctor, synthesize the previous situation and immediately put forward a set of detailed treatment plan for the next stage or relevant recommendations, including whether additional examination items are needed or not. 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 record-keeping function of traditional medical records is only one aspect of many functions in an electronic medical record.
2. The traditional medical record can not guarantee the integrity of the data, the electronic medical record can ensure complete, accurate and timely access to information.
This deficiency in traditional medical records stems from a number of sources.
First of all, the development of examination, treatment, monitoring and other technologies, even including the development of management technology are negating the traditional medical record. According to the original intention of case management, all patient-related information should be concentrated in the case for unified storage, X-rays were 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 tests, perioperative monitoring, dialysis treatment, rehabilitation and other tests and treatments to obtain a large amount of information are saved outside the case, the case is only a brief report into the case. What is in the case is only a short report or part of the brief image data, and in some cases, except for the medical advice and medical logs, there is even no specific information left in the case, and this information is scattered and kept in various professional departments or discarded.
On the other hand, due to the limitations of traditional medical records on paper, even if some information, such as a 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 stored in 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 easy 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 chart is bound to lose its raison d'être.
Secondly, the development of transportation has weakened people's concept of geography. The reform of the healthcare system has allowed patients to choose multiple hospitals to visit. A person can visit different hospitals in Beijing's east or west city, and may also visit hospitals 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 only limited to the form, the results of different hospitals, idioms, quality control standards, etc., other hospital doctors basically have no way to know.
Electronic medical records 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 is 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 yet given a diagnostic 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. Electronic medical records of different hospitals can be completed through the network and the necessary protocols, standards in the exchange of data transmission between hospitals, the doctor can get comprehensive information, the same does not have to care about the preservation of medical records location.
3. Traditional medical records can not get the necessary interpretation, can not be associated with knowledge
The so-called interpretation, is to explain the meaning. In the case of medical records, interpretation includes two aspects:
One is that different doctors or staff in different hospitals use the terminology or check the information recorded by the instrument, the actual meaning of which needs to be interpreted, so that different people can be correctly informed of the exact 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 medical records are read by non-medical persons such as patients or insurance company personnel.
The second is that for rusty terms or new concepts or new tests, treatment programs, new drugs, etc. caused by specialties, 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 function paper medical records are completely helpless.
4. 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 borrowed due to the case, not yet filed, lost, and other reasons for 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 a wireless network, the doctor can be at any time, such as on the road or in the meeting, access to medical records.
The above describes some of the major differences between an ideal electronic medical record and a traditional paper medical record. However, the reality of the electronic medical record, for various reasons, falls short of the ideal. The concept of the reality of electronic medical records is a concept of development, the concept of change, or electronic medical records have many versions of reality. 1, the overall design and planning to ensure the unity of information processing.
2, "full control method" management, effective prevention of sales risk.
3, modular combination to avoid the risk of developing from "zero".
4, business-oriented personalized design.
5, classic OFFICE interface, real operating environment.
6, matrix cross-privilege control reproduces the enterprise organizational structure and business processes.
7. Driven by autonomous tasks and controlled by PDCA ring, it comprehensively improves execution.
8, emphasizing the "effect" of information exchange, to put an end to paperwork. 1、Office Automation System (OA)
2、Decision Support System (BI)
3、Customer Relationship Management (CRM)
4、Sales Force Automation (SFA)
5、Human Resource Management System (HR)
6、Procurement Management System (SCM)
7、Project Management System (PM)
8, Contract Management System (CMS)
9, Market Management System (MMS)
10, Customer Service System (CSS)
11, Company Management System (CMS)
12, Knowledge Management System (KM)
13, Financial Management System (FMS)
14, System Base Management (SBM) EMR The implementation of EMR system is a very rigorous project because the system covers the main aspects of multiple operational processes of the enterprise. In order to ensure the interests of enterprises, from the preliminary preparation, the establishment of the implementation of the organization, the system research, product training, project implementation to after-sales support, have developed the appropriate processes and methods to truly enable enterprises to use, use and use well.