Shortliffe E H
Stanford University School of Medicine, California 94305-5479, USA.
Acad Med. 1999 Apr;74(4):414-9. doi: 10.1097/00001888-199904000-00038.
No clinical computing topic is being given more attention than that of electronic medical records. Health care organizations, finding that they do not have systems adequate for answering questions crucial to strategic planning and for remaining competitive with other provider groups, are looking to information technologies for help. Many institutions are developing integrated clinical workstations, which provide a single point of entry for access to patient-related, administrative, and research information. At the heart of the evolving clinical workstation lies the medical record in a new incarnation: electronic, accessible, confidential, secure, acceptable to clinicians and patients, and integrated with other, non-patient-specific information. The author describes the problems associated with paper-based record keeping and the promise of the electronic medical record, emphasizing the areas of clinical trials and decision support. He then discusses the issues that must be addressed and the requirements that must be met if electronic medical record systems are to move beyond intranet environments within single health systems or practices and to integrate with regional, national, and international resources via the Internet.
没有哪个临床计算主题比电子病历更受关注。医疗保健机构发现自己没有足够的系统来回答对战略规划至关重要的问题，也无法与其他医疗服务提供方竞争，于是寄希望于信息技术来提供帮助。许多机构正在开发集成临床工作站，它为获取患者相关信息、管理信息和研究信息提供了单一入口。不断发展的临床工作站的核心是焕然一新的病历：电子化、可访问、保密、安全、临床医生和患者都能接受，并且与其他非特定患者信息集成。作者描述了基于纸质记录保存所存在的问题以及电子病历的前景，重点强调了临床试验和决策支持领域。接着，他讨论了如果电子病历系统要超越单一医疗系统或医疗机构内部的内联网环境，并通过互联网与区域、国家和国际资源集成，必须解决的问题和必须满足的要求。
