Campion Francis X, Richter James M
Department of Population Medicine, Harvard Medical School, Boston, MA, USA.
J Med Pract Manage. 2011 Jul-Aug;27(1):50-6.
The adoption of electronic health records (EHRs) is now a national priority, but evidence shows that the level of typical adoption is low. We describe the goal of "high-level adoption" of an EHR system defined as a community of clinicians using an EHR system to share patient information, and create a summary of a patient's health, through the timely documentation of care, as well as through effective communication among caregivers, with a focus on patient safety and efficient use of resources. There are 10 key principles to achieving high level-adoption. These are: (1) shared medication lists; (2) shared patient problem lists; (3) established guidelines for communication about patient information among clinicians; (4) use of standard terminology; (5) preventive services; (6) integration of external data; (7) computerized provider order entry; (8) regional health information exchange; (9) adoption of clinical decision support; and (10) reuse of data for public health and research.
采用电子健康记录（EHRs）如今已成为国家优先事项，但有证据表明，典型的采用水平较低。我们描述了EHR系统“高水平采用”的目标，即一个临床医生群体使用EHR系统来共享患者信息，并通过及时记录护理情况以及护理人员之间的有效沟通，创建患者健康摘要，重点关注患者安全和资源的有效利用。实现高水平采用有10项关键原则。这些原则是：（1）共享用药清单；（2）共享患者问题清单；（3）制定临床医生之间关于患者信息沟通的指南；（4）使用标准术语；（5）预防服务；（6）整合外部数据；（7）计算机化医嘱录入；（8）区域健康信息交换；（9）采用临床决策支持；以及（10）将数据重新用于公共卫生和研究。
