Healthcare Informatics Engineering Research Center, Zhejiang University, Hangzhou, China.
J Med Syst. 2012 Jun;36(3):1193-203. doi: 10.1007/s10916-010-9581-1.
Current EMR system benefits physicians by facilitating order entry and reducing errors. It can improve the safety and effectiveness of medical services, but cannot manage the whole medical process and the quality of medical services. In addition to physicians, EMR should be designed for all medical professionals because medical services cannot be accomplished by physicians alone, but also requires the involvement of other medical professionals. Therefore, we applied PDCA, the famous quality management cycle to design a comprehensive and coherent EMR system which can be used throughout the entire treatment process. EMR with the PDCA Cycle can record every order state and every treatment procedure in order to monitor the whole medical process. This extends the safety from planning the treatment to fulfilling it. By analyzing the records, doctors and hospital managers can perfect the medical process and improve healthcare quality. The EMR we designed with the PDCA Cycle provides a record entry interface for physicians and a worksheet interface for nurses and other professionals. Every treatment procedure and every change of orders or tasks will be fed back to medical professionals. So information generated from the beginning to the end of treatment will link with each other to avoid any information islands. Furthermore, the EMR can display the additional information intuitively and real-timely without increasing the burden of medical professionals' work.
当前的电子病历系统通过方便医嘱录入和减少错误来使医生受益。它可以提高医疗服务的安全性和有效性，但无法管理整个医疗流程和医疗服务质量。除了医生，电子病历系统还应为所有医疗专业人员设计，因为医疗服务不能仅由医生完成，还需要其他医疗专业人员的参与。因此，我们应用了著名的质量管理循环 PDCA，来设计一个全面连贯的电子病历系统，该系统可以用于整个治疗过程。具有 PDCA 循环的电子病历可以记录每个医嘱状态和每个治疗步骤，以监控整个医疗流程。这将安全性从治疗计划扩展到实施。通过分析记录，医生和医院管理人员可以完善医疗流程并提高医疗保健质量。我们设计的具有 PDCA 循环的电子病历系统为医生提供了记录录入界面，为护士和其他专业人员提供了工作表界面。每个治疗步骤和每个医嘱或任务的变更都将反馈给医疗专业人员。因此，从治疗开始到结束产生的信息将相互关联，避免任何信息孤岛。此外，电子病历可以直观、实时地显示附加信息，而不会增加医疗专业人员的工作负担。
