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电子病历系统:医疗保健的奇迹还是困境?

The electronic medical record system: health care marvel or morass?

作者信息

Silverman D C

机构信息

BJC Health System, St. Louis, MO, USA.

出版信息

Physician Exec. 1998 May-Jun;24(3):26-30.

Abstract

The author considers the potential advantages and disadvantages, as well as possible unintended consequences, of introducing electronic medical record systems in health care organizations. Special consideration is given to the issues such information systems raise concerning privacy, confidentiality, and quality of care from both patient and provider perspectives. The potential gains from computerizing medical records include the benefit of instantaneous availability of patients' medical history, treatment regimes, and current health status in routine and emergency clinical situations. Ease of access to this information should reduce adverse outcomes. The added value of a complete and up-to-date medical record immediately available to medical caregivers seems undeniable. The potential disadvantages include issues around patient confidentiality and unauthorized access to records, the enormous capital investment for computer hardware, and system maintenance.

摘要

作者考虑了在医疗机构引入电子病历系统的潜在优势与劣势,以及可能产生的意外后果。从患者和医疗服务提供者的角度,特别关注了此类信息系统在隐私、保密和医疗质量方面引发的问题。将病历计算机化的潜在益处包括在常规和紧急临床情况下能即时获取患者的病史、治疗方案和当前健康状况。易于获取这些信息应能减少不良后果。医疗护理人员能即时获取完整且最新的病历,其附加价值似乎是不可否认的。潜在的劣势包括患者保密问题以及对记录的未经授权访问、计算机硬件的巨额资本投资和系统维护。

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