EMR, electronic medical record (EMR) is also called computerized medical record system or computer-based patient record (cardiopulmonary resuscitation). It is a digital patient medical record saved, managed, transmitted and copied by electronic equipment (computers, health cards, etc.). ) instead of handwritten paper medical records. Its content includes all the information of paper medical records. The National Institute of Medicine defines EMR as an electronic medical record based on a specific system, which provides users with the ability to access complete and accurate data, warnings, tips and clinical decision support systems.
The medical record is the original record of the whole process of the patient's diagnosis and treatment in the hospital, including the home page, course records, examination results, doctor's orders, operation records, nursing records, etc. Electronic medical record not only refers to static medical record information, but also includes related services provided. It is electronically managed information about personal lifelong health status and medical behavior, involving all the process information of patient information collection, storage, transmission, processing and utilization.
Electronic medical record is produced with the networking of hospital computer management, the application of information storage media CD and ic card and the globalization of Internet. Electronic medical record is the inevitable product of information technology and network technology in the medical field and the inevitable trend of modern management of hospital medical records. Its preliminary clinical application has greatly improved the work efficiency and medical quality of hospitals, but this is only the beginning of the application of electronic medical records.
What exactly is an electronic medical record, the academic community still lacks a unified understanding. According to the current research, the ideal electronic medical record should have two functions:
1. Doctors, patients or other authorized persons can obtain any individual health data or related information completely, accurately and timely under any circumstances, and can get accurate interpretation, and get detailed, accurate and comprehensive relevant knowledge to the maximum extent when necessary.
2. Electronic medical records can take the initiative to judge according to their own information and knowledge, make timely and accurate prompts when individual health needs to be adjusted, and give the optimal scheme and implementation scheme. It is called an ideal electronic medical record because these two functions seem simple, but in fact they have far-reaching significance, and it is difficult to fully realize them within several decades. After the introduction of the concept of electronic medical records, the paper medical records currently used are generally called traditional medical records, and the main differences with electronic medical records are as follows:
1. Traditional medical records are passive, static and isolated, while electronic medical records are active, dynamic and related. Traditional medical records simply do not have the second function of electronic medical records, that is, they have no initiative and intelligence, and they cannot be related to relevant knowledge. Paper medical records can be read and supplemented with new contents, but there is no organic connection between the contents, the contents of medical records are completely out of touch with the actual state of patients, and the contents of medical records are not connected with related knowledge, so medical records can only be recorded in the same order. The revolutionary difference of electronic medical record is that the information it stores is no longer isolated and static, but related and dynamic, not just block information, but a collection of knowledge. The new information will establish the necessary connection with all the existing information, change the structure, comprehensively analyze and judge the patient's status according to the existing knowledge, laws, rules and precedents, and actively remind the relevant doctors or patients; Put forward examination, treatment plan, etc. For example, the electronic medical record system for managing renal dialysis can record all relevant physiological indexes of patients and all previous dialysis information, which has been processed when entering the system. When the patient completes a dialysis treatment, the system will immediately put forward a set of detailed treatment plans or related suggestions according to the real-time detection of the instrument and the new examination results input by the doctor, including whether it is necessary to add examination items, whether it is necessary to use auxiliary drugs, and the measurement of drugs. After the doctor gives his own plan with reference to the plan provided by the system, the electronic medical record system will judge according to its stored knowledge, and will remind the doctor if there are contradictions or irregularities or violations of special principles. Doctors can ask contradictions about their principles and documents. If the doctor insists on his own plan and carries it out, and finally proves that the plan is effective, the electronic medical record system will learn the plan and save it as a precedent. This example shows that the recording function of traditional medical records is only one aspect of many functions of electronic medical records.
2. Traditional medical records cannot guarantee data integrity, while electronic medical records can ensure complete, accurate and timely access to information.
This defect of traditional medical records comes from many aspects.
First of all, the development of examination, treatment, monitoring and other technologies, including the development of management technology, are denying traditional medical records. According to the original intention of medical record management, all patients' related information should be centralized in the medical record for unified custody. X-rays were first managed separately from medical records, and pathological sections and smears were never classified as medical records. CT, B-ultrasound, nuclear magnetic resonance, perioperative monitoring, dialysis treatment, rehabilitation treatment and other imaging examinations obtained a lot of information. Apart from the medical records, only short reports or some short video materials entered the medical records, and some even left no specific information in the medical records except the doctor's advice and the course log. These information materials have been preserved.
On the other hand, due to the limitation of traditional medical record paper media, it is impossible to save some materials, such as Doppler ultrasound video, with medical records. After the information system is put into use, information such as doctor's orders is stored in the computer. Although there are still printed pages bound to medical records, fewer and fewer people view paper information. Based on the above situation, it is not difficult to see from the general trend that the proportion of patient information saved in medical records to the total patient information is rapidly declining, and in the not-too-distant future, paper medical records will inevitably lose their significance.
Secondly, the development of traffic has weakened people's regional concept. The reform of medical system enables patients to choose multiple hospitals for treatment. A person can see a doctor in different hospitals in Dongcheng or Xicheng, Beijing, or in hospitals in Shenzhen and Xi 'an. Using paper medical records, it is difficult for any hospital to get a patient's medical records from other hospitals. This difficulty is not limited to form. The examination results, idioms and quality control standards of different hospitals are basically unknown to doctors in other hospitals.
Electronic medical records can comprehensively manage all kinds of information.
It can be centralized management or decentralized management, and theoretically collect complete information of various decentralized management. For example, when a patient has a CT examination, the radiologist can see his image immediately, and the competent doctor can watch it in the ward at the same time through the electronic medical record system. However, at this time, because the radiologist has not given a diagnosis report, the relevant image data are mainly kept in the radiology department. After the diagnosis, the relevant information is automatically transmitted to the electronic medical record room through the computer network for permanent preservation. At this time, the doctor in charge can only know the different contents and where the specific information is, and there is no need or need to care. Electronic medical records of different hospitals can complete data transmission and exchange between hospitals through the network and necessary protocols and standards, and doctors can obtain comprehensive information, and they don't have to care about the storage location of medical records.
3. Traditional medical records can't get the necessary interpretation and knowledge association.
The so-called explanation is to explain the meaning. For medical records, interpretation includes two aspects:
First, the terms used by different doctors or staff in different hospitals or the information recorded by inspection instruments need to be explained, so that different people can know their exact meanings correctly. For example, the medical records of one hospital need to be interpreted in another hospital. Non-medical personnel such as patients or insurance company personnel need to interpret medical records at any time.
Second, explain the theoretical basis, significance, normal values and indications of unfamiliar terms or new concepts or new examinations, treatment items and new drugs caused by specialties, resources or new progress. Interpretation function needs the help of artificial intelligence technology, especially knowledge engineering. Knowledge association is of great significance to medical interns, senior doctors and junior doctors. Knowledge association is also helpful to solve the difficulty of reading medical records brought by specialization, and it is beneficial for doctors in low-level hospitals to enjoy the application of medical records in high-level hospitals. This kind of functional paper medical record is completely powerless.
4. Traditional medical records cannot be obtained in time and cannot be enjoyed.
In addition to the inconvenience caused by medical records belonging to different hospitals, the medical records of the same hospital can not be put in place in time because of the reasons such as medical records being borrowed, not filed and lost. The adoption of electronic medical records can completely change this situation. A patient's medical record can be obtained not only by many people at the same time, but also by different hospitals in different places. If a wireless network is connected, doctors can get medical records at any time, such as when traveling or meeting.
The above introduces some main differences between the ideal electronic medical record and the traditional paper medical record. However, due to various reasons, the existing electronic medical records can not achieve the expected results. The realistic concept of electronic medical record is a developing concept, a changing concept, or there are many realistic versions of electronic medical record. At present, the widely accepted definition of electronic medical record was put forward by American Institute of Medicine (IOM) 199 1+0. The original text is as follows:
"... an electronic medical record residing in a system dedicated to supporting users by providing complete and accurate data, doctors' reminders and alarms, clinical decision support systems, medical knowledge system links and other auxiliary tools."
Its translation is roughly as follows:
Electronic medical records exist in a special system. With this system, electronic medical records can support its users to obtain: complete and accurate information; Prompt and warn medical staff; Various medical decision support systems; Connecting medical knowledge sources; Other help.
This definition refers to a concept called electronic medical record system.
Traditional medical records require medical staff to record information with the help of paper and ink, and a group of professionals manually process, sort out and keep the medical records. A medical record is usually a pile of paper with information on it.
Electronic medical records need to be transformed into information forms that can interact with people with the help of computer equipment, and the functions of electronic medical records can be completed through the combination of data collection, recording, processing, storage, management and transmission. These tasks are accomplished by computer system, which is the electronic medical record system. Electronic medical record system is a computer system attached to electronic medical record, and it is a functional form or function of electronic medical record system. Compared with the concept of "system", medical staff pay more attention to the content of medical records and are willing to be concrete and visual, so the concept of electronic medical record system is usually vague, whether it is "system" or electronic medical record itself, it is generally called electronic medical record.
In the related literature of electronic medical records, there is a word called VMR virtual medical records. This word helps to understand electronic medical records.
The so-called virtual medical record refers to a computer system that manages a sufficient number and variety of medical record information, and can completely reproduce all the contents of paper medical records when necessary, but its data storage mode is not limited to the traditional medical record form. It should be noted that virtual medical records emphasize the ability of computerized medical record data to copy traditional medical records from form to content. For electronic medical records, the content and form of traditional medical records can be completely copied, but electronic medical records do not stick to copying, nor pursue copying, but pursue a more reasonable and efficient form. Pay attention to this when using the concepts of virtual medical records and electronic medical records.
Application status: In recent 20 years, some big hospitals in Europe and America began to establish hospital information systems (HIS), and then electronic medical records were studied and applied to a considerable extent in the United States, Britain, the Netherlands, Japan, Hong Kong and other regions. The American government has been vigorously promoting and popularizing the application of electronic medical records. The Medical College of Indiana University uses EMR to predict the mortality rate of early cancer patients, and the Boston EMR Association is studying the problem of transmitting EMR of emergency patients through the Internet. The IC card of EMR has been used in pregnancy information, labor process enlightenment and follow-up observation of pregnant women in Britain. The patient card of Hong Kong Hospital Authority records the patient's complete medical treatment process, including doctor's examination, laboratory 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 electronic medical records as a key topic, and organize medical units to implement and promote them.
After nearly 20 years of development, China's hospital information system has begun to take shape, and many hospitals have established hospital-wide information systems, represented by Huiyuan Hospital Management Information System of Dalian Huiyuan Electronic System Engineering Co., Ltd., which has laid a solid foundation for the research and application of electronic medical records in China. Jinweika supervised by the Ministry of Health will be introduced to the whole society. It can store cardholders' lifelong medical care information, and cardholders can directly connect with banks, medical insurance centers and insurance institutions through computer networks, making medical activities simple, convenient and fast. The General Hospital of PLA has carried out the research and application of electronic medical records. This is only the beginning of the research and application of electronic medical records, and the related research content will continue to deepen with the development of electronic medical records.
Relationship with him: 1. The electronic medical record is attached to his. Electronic medical record system is not a new system independent of HIS, because patient information comes from various business subsystems in HIS. For example, the first page of medical records comes from hospitalization registration, import and export, medical records cataloging and other systems. Each business system not only completes its own functions, manages its own business data, but also collects patient information. Therefore, without HIS, there would be no electronic medical record system. It can be said that electronic medical records have infiltrated into HIS.
2. The electronic medical record system is different from the traditional HIS system. From the perspective of electronic medical records, patient information is complete and complete; From each subsystem of traditional HIS, patient information is local and discrete, and there are redundancies and omissions between them. They are usually not designed and managed according to unified principles. In content, there are different emphases and requirements. For example, the first page management of medical records for the purpose of statistics and retrieval can only input and save the patient's diagnostic ICD code, but from the perspective of electronic medical records, the doctor's diagnostic description must be completely saved, and the diagnostic description and ICD classification code cannot replace each other. Electronic medical record emphasizes the originality and integrity of patient information.
Electronic medical record is produced with the networking of hospital computer management, the application of information storage media CD and ic card and the globalization of Internet. Electronic medical record is the inevitable product of information technology and network technology in the medical field and the inevitable trend of modern management of hospital medical records. Its preliminary clinical application has greatly improved the work efficiency and medical quality of hospitals, but this is only the beginning of the application of electronic medical records.
Advantages: 1, fast transmission speed. Medical staff can remotely access the patient's medical records through the computer network, and can transmit the data to the needed places within minutes or even seconds. In case of emergency, the information in electronic medical records can be found in time and displayed in front of doctors.
2. * * * Enjoy it. The routine medical records used now are very closed. The records of inpatients are kept only in this hospital. If patients go to other hospitals, they need to be re-examined, which not only wastes valuable medical resources, but also adds a lot of necessary pain to patients. These shortcomings can be overcome after the adoption of electronic medical records. The diagnosis and treatment results of patients in various hospitals can be transmitted through computer networks between hospitals or health cards (optical cards and IC cards) carried by patients. The enjoyment of medical records will bring great convenience to medical treatment.
3. Large storage capacity. Due to the progress of computer storage technology, especially CD-ROM technology, the storage capacity of electronic medical record system database can be quite huge, and the capacity of health cards (optical cards or ic cards) carried by patients is also considerable.
4. easy to use. Medical staff can conveniently store, retrieve and browse medical records by using the electronic medical record system, and can also conveniently make copies, and can carry out various scientific research and statistical analysis conveniently, quickly and accurately, which greatly reduces the workload of manually collecting and inputting data and greatly improves the level of clinical scientific research.
5. Low cost. After the electronic medical record system is put into use at one time, it can reduce the cost of patients and hospitals. At present, there are also some shortcomings in electronic medical records. For example, a lot of computer software and hardware investment and personnel training are needed, and some medical personnel even find it difficult to adapt to computer operation. Once the computer breaks down, it will cause the system to stop running and fail to work. Therefore, it is often necessary to save manual original records. In addition, all kinds of errors (mainly operational errors) often occur when inputting medical records into the computer, which requires strict inspection to prevent mistakes and accidents.
Main functions: 1, structured storage
2, medical record template library
3. Compulsory inspection
4. Support various medical special expressions (such as the formula expression of menstrual history, fetal heart rate and dental caries location).
5. Support the three-level examination (three-level audit) function of medical records.
6. Support the modification trace retention, and retain the modification trace of doctors at all levels.
7. Time-limited control mechanism, which adopts workflow-driven mode, automatically prompts tasks, reminds and urges medical staff in time, and completes medical record writing on time with good quality and quantity, effectively avoiding the omission, omission and delay of medical record documents.
8. Support data element binding and realize multi-document synchronous refresh technology.
9. Table processing ability (table medical records can be made conveniently), supporting table nesting, cell merging, cell splitting, row deletion, column deletion, row addition, column insertion, and manual or automatic adjustment of table width.
10, which supports the legality check of the input value.
Clinical information system with electronic medical record as the core: Electronic medical record is the core of hospital medical information system. The main function of medical information system is to provide information service for hospital medical treatment, and all its functions are based on the processing of patient medical records. It includes:
① Natural information such as patient's name and gender.
② Admission, discharge and transfer of patients.
(3) Records of patients receiving various examinations in the hospital.
(4) all kinds of treatment records made by doctors for patients.
⑤ Nursing records of patients, etc.
With the medical information system with electronic medical records as the core, the process of medical work will change greatly. If an emergency patient suddenly comes to the hospital, the doctor can insert the patient's health card into the computer, so that the computer will immediately display the patient's relevant information, such as name, age, drug sensitivity and so on. At this time, the doctor can make the required checklist according to the patient's clinical manifestations. After completing the examination, the attending doctor can get the examination results immediately and make suggestions for diagnosis and treatment. If it is a difficult case, the attending doctor can also ask a superior doctor or a specialist for consultation through the computer network system. Superior doctors or specialists can put forward consultation opinions in their own offices or homes to help doctors make treatment plans. The application of electronic medical records and computer information systems will greatly shorten the time and improve the quality of this medical consultation.
-1994 Viewscope, a multimedia electronic medical record system introduced from abroad, is a representative hospital information system with electronic medical records as its core. This system is a multimedia microcomputer system integrating image, video, audio and text. It can access information from multiple data sources at the same time, so that medical staff can view all the patient's medical records, such as X-rays and ultrasonic images, and watch videos and disease records from ordinary desktop microcomputer systems at one time. The information stored in the Viewscope system includes:
① Computed tomography (CT or CAT) images, nuclear magnetic resonance images, X-rays, ultrasonic images and photos;
(2) Medical records, charts, letters and documents;
③ Video recorded during the operation, etc.
(4) Relevant medical reports and X-ray interpretation records, etc.
Viewscope, a multimedia electronic medical record system, can also be connected with other medical information systems to form a hospital information system with electronic medical records as the core.