电子健康记录系统对信息完整性的影响：质量与安全方面的影响
Impact of electronic health record systems on information integrity: quality and safety implications.
作者信息
Bowman Sue
机构信息
Sue Bowman, MJ, RHIA, CCS, FAHIMA, is the senior director of coding policy and compliance at AHIMA in Chicago, IL.
出版信息
Perspect Health Inf Manag. 2013 Oct 1;10(Fall):1c. eCollection 2013.
Abstract
While the adoption of electronic health record (EHR) systems promises a number of substantial benefits, including better care and decreased healthcare costs, serious unintended consequences from the implementation of these systems have emerged. Poor EHR system design and improper use can cause EHR-related errors that jeopardize the integrity of the information in the EHR, leading to errors that endanger patient safety or decrease the quality of care. These unintended consequences also may increase fraud and abuse and can have serious legal implications. This literature review examines the impact of unintended consequences of the use of EHR systems on the quality of care and proposed solutions to address EHR-related errors. This analysis of the literature on EHR risks is intended to serve as an impetus for further research on the prevalence of these risks, their impact on quality and safety of patient care, and strategies for reducing them.
摘要
虽然采用电子健康记录（EHR）系统有望带来诸多重大益处，包括改善医疗服务和降低医疗成本，但这些系统实施过程中也出现了严重的意外后果。电子健康记录系统设计不佳和使用不当会导致与电子健康记录相关的错误，危及电子健康记录中信息的完整性，进而引发危及患者安全或降低医疗质量的错误。这些意外后果还可能增加欺诈和滥用行为，并可能产生严重的法律影响。本文献综述探讨了使用电子健康记录系统的意外后果对医疗质量的影响，并提出了解决与电子健康记录相关错误的方案。对电子健康记录风险文献的这一分析旨在推动对这些风险的普遍性、它们对患者医疗质量和安全的影响以及降低这些风险的策略进行进一步研究。
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