Knaup Petra, Bott Oliver, Kohl Christian, Lovis Christian, Garde Sebastian
Department of Medical Informatics, University of Heidelberg, Germany.
Yearb Med Inform. 2007:34-46.
Electronic patient record (EPR) systems are increasingly used and have matured sufficiently so as to contribute to high quality care and efficient patient management. Our objective is to summarize current trends and major achievements in the field of EPR in the last year and to discuss their future prospects.
Integrating health data from a variety of sources in a comprehensive EPR is a major prerequisite for e-health and e-research. Current research continues to elaborate architectures, technologies and security concepts. To achieve semantic interoperability standards are developed on different levels, including basic data types, messages, services, architectures, terminologies, ontologies, scope and presentation of EPR content. Standards development organisations have started to harmonize their work to arrive at a consensus standard for EPR systems. Integrating the health care enterprise as a whole will optimize efficient use of resources, logistics and scheduling.
The past few years have seen a myriad of developments of EPR systems. However, it is still a long way, until EPR systems can flexibly fulfill all user requirements and an EHR will become broadly accepted. Semantic interoperability will be a key to successful EPR use, especially to avoid double data entries and to better integrate data recording within local workflows. The patient will become an empowered partner, not only by giving him access to his health data. All this will result in enormous quantities of data. Thus, time has come to determine how relevant data can be presented to the stakeholders adequately.
电子病历(EPR)系统的使用日益广泛且已足够成熟,有助于提供高质量医疗服务和实现高效的患者管理。我们的目标是总结过去一年电子病历领域的当前趋势和主要成就,并探讨其未来前景。
在综合电子病历中整合来自各种来源的健康数据是电子健康和电子研究的主要前提。当前的研究继续阐述架构、技术和安全概念。为实现语义互操作性,在不同层面制定了标准,包括基本数据类型、消息、服务、架构、术语、本体、电子病历内容的范围和呈现方式。标准制定组织已开始协调其工作,以达成电子病历系统的共识标准。整合整个医疗保健企业将优化资源、物流和调度的高效利用。
过去几年电子病历系统有众多发展。然而,要使电子病历系统能够灵活满足所有用户需求并使电子健康记录得到广泛接受,仍有很长的路要走。语义互操作性将是成功使用电子病历的关键,特别是有助于避免重复数据录入并更好地将数据记录整合到本地工作流程中。患者不仅可以访问自己的健康数据,还将成为有能力的合作伙伴。所有这些将产生大量数据。因此,现在是时候确定如何将相关数据充分呈现给利益相关者了。