The electronic medical record 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:
①Patient's name, gender and other natural information.
②Popularity of the patient's admission, discharge, transfer, transfer and so on.
③ Records of various examinations the patient received in the hospital.
④ Records of various treatments performed by the physician for the patient.
⑤ Records of nursing care for the patient, etc.
With the medical information system centered on electronic medical records, the process of medical work will change greatly. 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 display the patient's relevant information, 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 to check the 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 shortened, the quality is greatly improved.
Foreign countries 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 the medical staff can be from an ordinary desktop microcomputer system to access all the patient's medical records at once, such as X-ray film and ultrasound images, watch the condition of the records of video and audio recordings, etc. Viewscope system in the storage of information The information stored in the Viewscope system includes:
①computed tomography (CT or CAT) images, MR*** vibration images, X-rays, ultrasound images, and photographs;
②documents such as charts, graphs, letters, and receipts;
③video footage recorded during an operation;
④medical reports and audio recordings interpreting the X-ray films.
In addition to the information stored in the Viewscope system, the Viewscope system can also be used to access all of the patient's medical records, such as X-ray and ultrasound images, and to view video recordings of medical conditions.
Viewscope, a multimedia electronic medical record system, can also be linked with other medical information systems to form a hospital information system with electronic medical records as its core. 2. Traditional medical records can not guarantee the integrity of the data, electronic medical records can ensure complete, accurate and timely access to information.
Traditional medical records of this defect from many aspects.
First of all, the development of examination, 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 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 for data transmission and exchange between hospitals, the doctor can get comprehensive information, the same does not have to care about the preservation of the location of the medical records. 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. For the case, interpretation includes two aspects:
One is that different hospitals, different doctors or staff use the terminology or check the information recorded by the instrument, the actual meaning of the need to explain, 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 kind 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 due to the inconvenience caused by access, the same hospital will also be borrowed due to the case is 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 more people at the same time access, 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 the electronic medical record is a developing concept, a changing concept, or there are many versions of the reality of the electronic medical record. The 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 information. links to bodies of medical knowledge and other aids.
The translation is along the following lines:
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 team 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 an interactive form of information 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 record dependent on the existence of a computer system, electronic medical record is the electronic medical record system function form or function collectively. Because than the concept of the system, health care workers are more concerned about the content of the medical record, and willing to be specific, visualization, so usually vague use of the concept of electronic medical record system, whether it is the 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 in understanding the EHR.
The so-called virtual medical record refers to a computer system that manages a sufficient amount and type of medical record information to completely reproduce the entire content of a paper medical record when needed, but its data is stored in a way that is not confined to the traditional form of medical record. 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 concept needs attention.