Rossi Mori Angelo, Consorti Fabrizio, Ricci Fabrizio L
Istituto Tecnologie Biomediche, Consiglio Nazionale delle Ricerche, Roma, Italy.
Stud Health Technol Inform. 2002;87:102-14.
Increasing cooperation among health professionals--within and across organizations--require a suitable sharing of clinical information from heterogeneous (electronic) documentation. Information originates from healthcare activities and may be organized within record systems in relation to health issues, episodes of care, episodes of illness, etc. Implementation of record systems depends on tasks and attitudes within each particular healthcare environment, that determine (i) the balance among functions of the record system, e.g. supporting human memory and decision making, supporting workflow management, recording circumstances about stored data, (ii) the particular organization of a record, (iii) the details of clinical statements that should be explicit or understood. In this paper we present a set of features of record systems and of their context that affect sharing of clinical information.
加强卫生专业人员之间（在组织内部以及跨组织）的合作，需要从异构（电子）文档中适当地共享临床信息。信息源自医疗保健活动，并且可能在记录系统中围绕健康问题、护理事件、疾病发作等进行组织。记录系统的实施取决于每个特定医疗保健环境中的任务和态度，这些任务和态度决定了：（i）记录系统各项功能之间的平衡，例如支持人类记忆和决策、支持工作流程管理、记录有关存储数据的情况；（ii）记录的特定组织方式；（iii）临床陈述应明确或易懂的细节。在本文中，我们介绍了影响临床信息共享的记录系统及其背景的一系列特征。
