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精神病学与电子健康记录的合理使用。

Psychiatry and the meaningful use of electronic health records.

作者信息

Triplett Patrick

出版信息

Perspect Biol Med. 2013 Summer;56(3):407-21. doi: 10.1353/pbm.2013.0028.

Abstract

Use of electronic health records (EHRs) for psychiatric care is on the rise, although the software and the workflow patterns on which the software has been built are often based on non-psychiatric practices. For providers, the transition from paper psychiatric records to electronic ones requires the development of a new set of skills that includes accommodating the physical presence of the computer and performing various forms of data entry, while still managing to carry out the tasks required for psychiatric practice. These changes alter the dynamic of communication, including elements of assessment and treatment that occur between the psychiatrist and patient. EHRs also raise issues of security of records and greater access by patients to providers and their records. Although EHRs promise an abundance of useful data for research and potentially helpful innovations, they also impose a practice pattern on psychiatry that is made to work largely through the efforts of the physician. EHRs do not enhance interactions in the psychiatric examination room, but instead alter the traditional pattern on which the doctor-patient relationship is founded in psychiatry and through which care is delivered.

摘要

电子健康记录(EHRs)在精神科护理中的使用正在增加,尽管软件及其构建所基于的工作流程模式通常是基于非精神科实践的。对于医疗服务提供者而言,从纸质精神科记录过渡到电子记录需要培养一套新技能,包括适应计算机的实际存在并进行各种形式的数据录入,同时仍要设法完成精神科实践所需的任务。这些变化改变了沟通的动态,包括精神科医生和患者之间发生的评估和治疗要素。电子健康记录还引发了记录安全以及患者对医疗服务提供者及其记录有更多访问权的问题。尽管电子健康记录有望为研究提供大量有用数据并带来潜在的有益创新,但它们也给精神病学带来了一种实践模式,这种模式很大程度上要通过医生的努力才能发挥作用。电子健康记录并没有增强精神科检查室中的互动,而是改变了精神病学中医患关系建立以及护理提供所基于的传统模式。

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