Electronic Medical Record (EMR) is also called a computerized medical record system or Computer-Based Patrient Record (CPR). It replaces the handwritten paper medical record with a digital patient's medical record that is stored, managed, transmitted, and reproduced using electronic devices (computers, health cards, etc.). Its content includes all information about paper medical records. The National Institute of Medical Research will define: EMR is an electronic patient record based on a specific system that provides users with access to complete and accurate data, alerts, prompts, and clinical decision support systems.
Electronic medical records are generated by the network management of hospital computers, the application of information storage media--discs and IC cards, and the globalization of the Internet. Electronic medical records are the inevitable outcome of information technology and network technology in the medical field. It is an inevitable trend in the modern management of hospital medical records. Its preliminary application in the clinic has greatly improved the efficiency and quality of hospital work, but this is only an electronic medical record. The start of the application.
1, structured storage
2, medical record template library
3. Required fields check
4, support a variety of medical-specific expressions (such as the history of menstruation, fetal heart, caries position formula).
5, support medical record document three-level inspection (three-level review) function
6, support the revision of trace retention, retain the traces of revision of doctors at all levels
7. Time-effect control mechanism adopts workflow main push mode, task automatically prompts, promptly reminds and urges medical staff to complete medical record writing work on time, quality and quantity, effectively avoiding lack of writing, missing writing and delayed writing of medical record documents. .
8, support data element binding, achieve multi-document synchronous refresh technology
9, table processing capabilities (can easily create a table medical record), support table nesting, merge cells, split cells, delete rows, delete columns, add rows, add columns, insert elements in the table, table width manually or automatically Adjustment
10, support input value legality check
Advantage1, the transmission speed is fast. Medical staff can remotely access patient medical records through a computer network, and can transfer data to where it is needed in minutes or even seconds. In the emergency department, the information in the electronic medical record can be detected and displayed in front of the doctor in time.
2, good sharing. The regular medical records currently used are largely closed. The records of hospital diagnosis and treatment are only kept in the hospital. If the patient visits other hospitals, it needs to be re-examined. This not only wastes valuable medical resources but also increases the necessary pain for the patients. After using the electronic medical record, you can overcome these shortcomings. The results of the patient's diagnosis and treatment in each hospital can be transmitted through the computer network between the hospitals or the health card (optical card and IC card) carried by the patient. The sharing of medical records will bring great convenience to medical care.
3. Large storage capacity. Due to the advancement of computer storage technology, especially optical disk technology, the storage capacity of the electronic medical record system database can be quite large, and the capacity of the health card (optical card or IC card) carried by the patient is considerable.
4, easy to use. Medical staff can use the electronic medical record system to conveniently store, retrieve and browse medical records, and it is also very convenient to copy. It can carry out various scientific research and statistical analysis work conveniently, quickly and accurately, greatly reducing the workload of manually collecting and inputting data. Greatly improve the level of clinical research.
5. Low cost. After the one-time investment in the electronic medical record system is completed, the cost of the patient and the expenses of the hospital can be reduced during use. At present, electronic medical records also have some shortcomings. For example, a large amount of computer hardware and software investment and personnel training are required, and some medical personnel are even difficult to adapt to computer operations. In the event of a computer failure, the system will be stalled and unable to work, so it is often necessary to save the original raw records. There are also various errors (mainly operational errors) that often occur when entering medical record data into a computer, and strict checks are required to prevent errors and accidents.
Application statusFor more than 20 years, some large hospitals in Europe and the United States have begun to establish hospital information systems (HIS) within the hospital. The electronic medical records have been studied and applied in the United States, the United Kingdom, the Netherlands, Japan, Hong Kong and other regions. The US government has been promoting and popularizing the application of EMR. The University of Indiana Medical School uses EMR to predict the mortality rate of early cancer patients. The Boston EMR Association is studying the transmission of EMR problems in emergency patients via the Internet. The UK has applied EMR's IC card to pregnant women's pregnancy information, labor inspiration and follow-up observation. The Hospital Authority's Patient Card (PaTIent Card) records the patient's complete medical procedure, including doctor's examination, test results, X-rays, CT MTI films and prescriptions. At the same time, these countries and regions have set up specialized research institutions to study EMR as a key topic and organize the implementation and popularization of medical units. After nearly 20 years of development, China's hospital information system has begun to take shape. Many hospitals have successively established hospital-wide information systems. The representative of Huiyuan Hospital Management Information System of Dalian Huiyuan Electronic System Engineering Co., Ltd. is the research of electronic medical records in China. And the application laid a solid foundation. Jinweika, which is supervised by the Ministry of Health of the People's Republic of China, will be launched to the whole society to preserve the cardholder's lifelong health care information. Cardholders can directly connect with banks, medical insurance centers and insurance institutions through computer networks to make medical activities simple. ,Convenient. The General Hospital of the People's Liberation Army carried out research and application of EMR. This is just the beginning of EMR research and application, and the relevant research content will be deepened with the development of EMR.
Relationship with HIS1. The electronic medical record is attached to the HIS. The electronic medical record system is not a new system independent of HIS because patient information is derived from various business subsystems in the HIS. For example, the first page of the medical record comes from the system of hospitalization registration, entry and exit, and medical record cataloging. Each business system collects patient information while completing its own functions and managing its own business data. Therefore, without the HIS, there is no electronic medical record system. It can be said that the electronic medical record penetrates into the HIS.
2. The electronic medical record system is different from the traditional HIS. From the perspective of electronic medical records, patient information is complete and integrated. From the perspective of each sub-system of traditional HIS, patient information is partial and discrete. The information between them is redundant and missing. Designed and managed in accordance with a unified principle. There are different emphasis and requirements on the content. For example, the diagnosis of the patient's home page for the purpose of statistics and retrieval can be as long as the ICD code is saved, and from the perspective of the electronic medical record, the doctor's diagnosis description must be completely preserved. The diagnostic description and the ICD classification code cannot replace each other. . Electronic medical records emphasize the originality and integrity of patient information.
Clinical information system with electronic medical record as the core
Electronic medical records are the core of medical information systems in hospitals. The main function of the medical information system is to provide information services for the hospital's medical care, and its functions are based on the processing of the patient's medical record information. it includes:
1 Natural information such as the patient's name and gender.
2 The prevalence of patients' admission, discharge, transfer, and transfer.
3 Various examination records accepted by the patient in the hospital.
4 Various treatment records made by the physician for the patient.
5 patient care records, etc.
With the medical information system with electronic medical records as the core, the process of medical work will change a lot. If an emergency patient suddenly comes to the hospital, the doctor can insert the health card carried on the patient into the computer, so that the computer will immediately display the patient's condition, such as name, age, drug sensitivity, etc., then the physician can The patient's clinical performance provides the required checklist. After the examination is completed, the doctor can immediately get the results of the examination and make a diagnosis and treatment opinion. If it is a difficult case, the treating physician can also consult a superior doctor or specialist through a computer network system. A superior physician or specialist can present a consultation in his or her office or at home to help the treating physician make a treatment plan. The application of electronic medical records and computer information systems will greatly shorten the time for this medical consultation and greatly improve the quality.
The multimedia electronic medical record system introduced in 1994, Viewscope, is a representative hospital information system with electronic medical records as the core. The system is a multimedia microcomputer system that integrates image, video, audio and text. It can access information from multiple data sources at the same time, enabling medical staff to access all the patients concerned from a common desktop computer system. Record medical records, such as X-rays and ultrasound images, and watch videos and recordings of illness records. The information stored in the Viewscope system includes:
1 computed tomography (CT or CAT) images, nuclear magnetic resonance images, X-ray films, ultrasound images, photos, etc.;
2 medical records, charts, letters and documents;
3 video recordings recorded during surgery, etc.;
4 related medical reports and recordings of X-ray films.
The multimedia electronic medical record system Viewscope can also be connected with other medical information systems to form a hospital information system with electronic medical records as the core.
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