Chin H L, Krall M A
Kaiser Permanente, Northwest Division, Portland, OR, USA.
Eff Clin Pract. 1998 Oct-Nov;1(2):51-60.
Kaiser Permanente Northwest (KPNW) has implemented a computer-based patient record (CPR) system for outpatients. Clinicians at KPNW use this comprehensive CPR to electronically document patient encounters; code diagnoses and procedures; maintain problem lists; order laboratory tests, radiology tests, and prescriptions; and send patient-specific messages and referrals to other medical providers. More than 700 clinicians, representing more than 20 medical and surgical specialties, and 2600 support staff in 31 geographically separate sites use this system as the information foundation of delivery and documentation of health care for KPNW's membership of 430,000. As of May 1998, more than four million visits and two million telephone calls had been processed and documented into the system. More than 5000 outpatient visits are processed and documented each weekday. From an integrated clinical workstation, clinicians also access e-mail, an extensive results-reporting system, and sites on both the internet and KPNW's intranet. This article describes a strategy for and experience with the implementation of a large-scale, comprehensive CPR in an integrated HMO. This information may be useful for persons attempting to implement CPRs in their own institutions.
凯撒医疗集团西北分部（KPNW）已为门诊患者实施了基于计算机的患者记录（CPR）系统。KPNW的临床医生使用这个综合的CPR系统以电子方式记录患者诊疗情况；对诊断和治疗程序进行编码；维护问题清单；开具实验室检查、放射检查和处方；并向其他医疗服务提供者发送特定患者的信息和转诊。来自20多个医学和外科专科的700多名临床医生以及分布在31个地理位置分散地点的2600名支持人员使用该系统，作为为KPNW的43万会员提供医疗服务和记录的信息基础。截至1998年5月，该系统已处理并记录了超过400万次就诊和200万个电话。每个工作日处理并记录的门诊就诊超过5000次。临床医生还可以从集成临床工作站访问电子邮件、一个广泛的结果报告系统以及互联网和KPNW内部网上的站点。本文描述了在一家综合健康维护组织（HMO）中实施大规模、综合CPR的策略和经验。这些信息可能对试图在自己机构中实施CPR的人有用。
