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文档完整性:沙特阿拉伯医院电子病历的作者功能。

Documentation integrity: Authorship functionalities of EHR in a Saudi Arabian hospital.

机构信息

Department of Health Informatics, College of Public Health & Health Informatics, King Saud Bin Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia.

出版信息

Comput Biol Med. 2018 Feb 1;93:184-188. doi: 10.1016/j.compbiomed.2017.12.015. Epub 2017 Dec 25.

DOI:10.1016/j.compbiomed.2017.12.015
PMID:29324363
Abstract

This paper aims to evaluate the authorship, privacy capabilities and functions of QuadraMed and BestCare systems, implemented at the Ministry of National Guard Health Affairs (MNGHA) in Riyadh, Saudi Arabia. A survey was conducted by interviewing back-end users of the EMR system in the KAMC hospital to check the aforementioned systems' authorship capabilities. Both the systems scored the same, with the overall result being 146/165 including the compliance level, which represents 88% availability of all authorship functions. The Quadra system's non-complying item was identified for only one entity, which is related to the lack of diagnosis documentation. It does not aid physicians in enhancing their ability to document diagnosis, which depends on coding and has not been implemented within the system so far. However, BestCare system provides documenting diagnosis depending on the coding part rather than free text, suggesting it is a promising system with enhanced functionalities.

摘要

本文旨在评估在沙特阿拉伯利雅得的沙特国民警卫队卫生事务部(MNGHA)实施的 QuadraMed 和 BestCare 系统的作者身份、隐私功能和特性。通过对 KAMC 医院电子病历系统后端用户进行调查,检查了上述系统的作者身份功能。这两个系统的评分相同,总分为 165 分中的 146 分,其中合规水平代表所有作者身份功能的 88%可用。Quadra 系统的不合规项目仅针对一个实体,这与缺乏诊断文档有关。它不能帮助医生提高诊断记录的能力,这取决于编码,而且迄今为止尚未在系统中实现。然而,BestCare 系统提供了基于编码部分的诊断记录,而不是自由文本,这表明它是一个具有增强功能的有前途的系统。

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