Turina Matthias, Kiran Ravi P
Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.
Clin Colon Rectal Surg. 2013 Mar;26(1):17-22. doi: 10.1055/s-0033-1333629.
Electronic medical records (EMRs) are being widely implemented today, either as stand-alone applications in smaller practices or as systems-based integrated network solutions in larger health care organizations. Advantages include rapid accessibility, worldwide availability, ease of storage, and secure transfer of protected health information (PHI). Computerized physician order entry (CPOE) and decision-support capabilities such as the triggering of an alarm when multiple medications with known interactions are ordered, as well as the seemingly endless possibilities for electronic integration and extraction of PHI for clinical and research purposes, have created opportunities and pitfalls alike. Risks include breaches of confidentiality with a need to implement tighter measures for electronic security. These measures contrast efforts required for the realization of common data formats that have national and even international compatibility. EMRs provide a common platform that could potentially allow for the integration and administration of clinical care, research, and quality metrics, thus promoting optimal outcomes for patients. Technical and medicolegal difficulties need to be overcome in the years to come so that the safe use of PHI can be ensured while still maintaining the benefits and convenience of modern EMR systems.
如今,电子病历(EMR)正在广泛实施,在较小规模的医疗机构中作为独立应用程序,或在较大的医疗保健组织中作为基于系统的集成网络解决方案。其优点包括快速可及性、全球可用性、易于存储以及受保护健康信息(PHI)的安全传输。计算机化医师医嘱录入(CPOE)和决策支持功能,例如当开出多种已知相互作用的药物时触发警报,以及出于临床和研究目的对PHI进行电子整合和提取的看似无穷的可能性,既创造了机会,也带来了隐患。风险包括保密性遭到破坏,需要实施更严格的电子安全措施。这些措施与实现具有国家甚至国际兼容性的通用数据格式所需的努力形成对比。电子病历提供了一个通用平台,有可能实现临床护理、研究和质量指标的整合与管理,从而为患者带来最佳结果。在未来几年,需要克服技术和法医学方面的困难,以便在确保安全使用PHI的同时,仍能保持现代电子病历系统的益处和便利性。