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[历经艰难,方达星辰:大学眼科医院电子病历的实施:萨尔兰大学医学中心眼科诊所使用FIDUS的经验]

[Per aspera ad astra: implementation of electronic patient records in a university eye hospital : Experience with FIDUS in the Clinic for Ophthalmology at the Saarland University Medical Center UKS].

作者信息

Spira-Eppig C, Eppig T, Bischof M, Schießl G, Milioti G, Käsmann-Kellner B, Carstensen H, Schick B, Seitz B

机构信息

Klinik für Augenheilkunde, Universitätsklinikum des Saarlandes UKS, Kirrberger Str. 100, Gebäude 22, 66421, Homburg/Saar, Deutschland.

Institut für Experimentelle Ophthalmologie, Universität des Saarlandes, 66421, Homburg/Saar, Deutschland.

出版信息

Ophthalmologe. 2018 Oct;115(10):868-877. doi: 10.1007/s00347-017-0588-6.

Abstract

BACKGROUND

For more than 60 years patient records of the Department of Ophthalmology at the Saarland Medical Center in Homburg were documented on handwritten paper documents and filed in archives. Increasing requirements for medical documentation, exploding volumes of diagnostic data, overcrowded archives and unavailable files when needed, were the essential rationales for the implementation of an electronic patient archive (EPA).

METHODS

The EPA has been specifically adapted to the requirements of the Department of Ophthalmology in order to guarantee a standardized unobstructed documentation and patient care across all sections of the department. Seamless integration into the clinic information system (KIS) and network-compatible diagnostic software were essential as well as a timely digitization of existing paper charts. Decisive factors for using FIDUS (Arztservice Wente GmbH, Darmstadt, Germany) as the EPA software were the visual layout of the EPA, user friendliness and reference installations of the software in other ophthalmology departments.

RESULTS

After one and a half years of meticulous preparation with specific adaptations to the requirements of our department, the EPA was finally implemented in January 2016 and since then we have been working on improvements. The EPA software retrieves basic patient data from the KIS and diagnostic data from electronic devices via various interfaces. Expenses for printers could be reduced but computer workplaces had to be expanded or newly created. For previous patients paper files are digitized externally and stored in an electronic archive directly accessible from the EPA.

DISCUSSION

Successful reorganization and implementation of electronic documentation during clinical routine is feasible with careful preparation and timely involvement of information technology experts, motivated physicians, nurses, research departments and the administration.

摘要

背景

60多年来,洪堡萨尔州医疗中心眼科的患者记录都记录在手写纸质文档上并存档于档案室。对医疗文档的要求不断提高、诊断数据量激增、档案室拥挤不堪以及需要时文件无法获取,这些都是实施电子患者档案(EPA)的主要理由。

方法

EPA已专门针对眼科的要求进行了调整,以确保该科室所有部门的文档记录和患者护理标准化且畅通无阻。无缝集成到临床信息系统(KIS)和网络兼容的诊断软件至关重要,同时现有纸质病历的及时数字化也很关键。选择FIDUS(德国达姆施塔特的Arztservice Wente GmbH公司)作为EPA软件的决定性因素包括EPA的可视化布局、用户友好性以及该软件在其他眼科部门的参考安装情况。

结果

经过一年半针对我们科室要求的精心准备,EPA最终于2016年1月实施,从那时起我们一直在进行改进。EPA软件通过各种接口从KIS检索患者基本数据,并从电子设备检索诊断数据。打印机费用得以降低,但计算机工作区必须扩大或新建。对于以前的患者,纸质文件在外部进行数字化处理,并存储在可从EPA直接访问的电子档案中。

讨论

在临床日常工作中成功重组和实施电子文档记录,通过精心准备以及信息技术专家、积极主动的医生、护士、研究部门和管理层的及时参与是可行的。

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