Hospital CIO of electronic medical record and electronic medical record system (1)

New health reform stated: "hospital management and electronic medical record, with the focus on advancing the hospital Informationization construction.

"Electronic medical records to health administrative departments and all levels of medical institutions, become health information of the hottest topics. The Ministry of health has enacted the electronic medical record basic schema and data standards and the fundamental norms of electronic medical records (for trial implementation) ", from the technical and management perspective on electronic medical record content specification, believe in promoting the development of China's electronic medical record will have a positive effect.

General Hospital of Nanjing military as a whole, Fuzhou and national digitization demonstration units, electronic medical record for an active exploration and practice.

In June, 2010 in Fuzhou General Hospital "Army" seminar on digital hospital building, Fuzhou General Hospital's electronic medical record system leaders and delegates. This article attempts to electronic medical record and electronic medical record systems to systematically expounded, hope to promote China's electronic records and electronic medical record system for health development.

Basic concepts

Electronic medical record development time is short, its connotation and denotation is undergoing continuous exploration and development, there is no unified definition.

Despite the different institutions on electronic medical record definitions vary, but are basically from electronic medical records shall include the information content and electronic medical record system should meet the two aspects of the function.

At present we usually refers to the electronic patient record includes the electronic medical record shall include the information content, including the electronic patient record system shall meet, as the basic concepts, information, content, system functionality is not enough clear, affecting the development of electronic medical records, there was a need for further clarification.

EMR (Electronic Medical Record, EMR) is the medical institutions and medical staff on outpatient, inpatient (or health) clinical diagnosis and treatment and guidance of the intervention, the use of information system-generated text, symbols, graphs, graphics, data, images, and so the digitized medical records service, is the resident individuals in medical institutions of various treatment process and is a complete, detailed records of clinical information resource, it can be used in medical and health services as the primary source of information, replacing paper medical records.

The electronic medical record defined here, mainly refers to the content of information to be included, is a static concept.

Electronic medical records system (Electronic Medical Record System, EMRS) is based on computer and information networks, electronic medical records to collect, store, display, retrieve, and process system.

Here the definition of electronic medical records system, mainly refers to the system function, is a dynamic concept.

Electronic medical record system emphasizes the role of information technology, provides services beyond paper medical records.

Electronic medical record systems from three aspects reflects its main features: a medical information record, store and access features; the second is the use of medical knowledge base to assist physicians in clinical decision making functions; the third is for public health and research services of information and functionality.

Although conceptually to strictly separate electronic medical record and electronic medical record system, but because the relationship is very close, sometimes not strictly distinguish between, and use electronic medical records to collectively referred to as electronic medical records and electronic medical record system.

Functional positioning

1. the electronic medical record information content localization of function has the following three characteristics.

A is the total factor of clinical diagnosis and treatment information.

Due to the lack of clinical information system support, the earliest Chinese electronic medical record is the record from the course Editor, so now we've got a lot of people consider e-course record is equivalent to the electronic medical record, this is an electronic medical record knew a misunderstanding. A true electronic medical record is the integration and fusion patient during medical procedures in all clinical information, not only can replace the paper records, it also goes far beyond the contents of the paper records, such as dynamic, medical imaging, drug supplies manufacturer and supplier of inspection equipment, more detailed information.

The second is the only medical institution.

Electronic medical record is a single medical institutions with clinical information total factor records, electronic medical records content legally responsible. Cross-sector of clinical diagnosis and management of information shared and personal health records (e.g., immunization, health check, health status, etc.) should belong to the management of electronic health records.

Third, and electronic health records.

Electronic health records (EHR, Electronic Health Record) is to the hospital's electronic medical record as subject to information sharing as the core of health records. EHR across different institutions and systems in the different information providers and users of information exchange between health care and sharing.

The Ministry of health to establish the "based on electronic medical records of hospital information system construction" and "based on health records of regional health information platform" has made it perfectly clear that electronic medical record and positioning of electronic health records and the main content area.

2. press the system functional scope to divide, electronic medical record system can be divided into narrowly and broadly.

Narrow electronic medical records system is not responsible for the content of medical records, only collect, store, display, retrieve and process.

Thus doctor's advice, the course record editor and other systems are not part of the electronic patient record system, integrated into the clinical information systems.

Generalized of electronic medical records system is not only responsible for the content of electronic medical records to collect, store, display, retrieve and handle, all with electronic medical record system are related to the electronic medical record system of category.

Not only the doctor's advice, the course record editor belonging to electronic medical records system, PACS/RIS, LIS, intensive care, surgical anesthesia system, care systems and electronic medical record content related parts such as diagnostic report system belong to the category of electronic medical records system; but the Department management component (such as the departments of internal shifts, appointments, and workload statistics, etc) do not fall within the electronic patient record system.

Construction target

Electronic medical record system is based on the patient-centered all hospital

Treatment procedure for data records that are based on the doctor's advice, examination, medical imaging, ECG, surgery, care, and other clinical information system, clinical site to meet the information needs, improve clinical decision-making and integrated medical information platform, a complete show clinical data integration, as well as intelligent application become the target of the development of electronic medical records, its development and application of the maximum level on behalf of the digital hospital construction. You can use the "Paperless storage, integrated show, intelligent application" to high-level electronic medical record should possess the core elements and construction.