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[医院信息系统中的电子病历]

[Electronic patient files in hospital information systems].

作者信息

Mir Mohi Sefat Armin, Patermann Katrin, von Ohlen Lars, Kühr Andrea, Ranjbar Mahdy, Pauls Werner, Dück Rudolf, Grisanti Salvatore

机构信息

Klinik für Augenheilkunde, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland.

UKSH Gesellschaft für IT Services mbH, Maria-Goeppert-Straße 7, Lübeck, 23562 Lübeck, Deutschland.

出版信息

Ophthalmologe. 2020 Oct;117(10):1015-1024. doi: 10.1007/s00347-020-01048-y.

Abstract

BACKGROUND

The implementation of an electronic patient health record (EHR) system in the field of ophthalmology can be a challenging project for many hospitals. Although all hospitals have a hospital information systems (HIS), these systems are often not capable of managing the complexity of ophthalmological patient records.

METHODS

This article reports the implementation of an ophthalmological EHR into the pre-existing HIS (Agfa-ORBIS; Agfa HealthCare GmbH, Bonn, Germany). The digital record management and the connections to the peripheral examination devices are presented.

RESULTS

The EHR developed by us has been in clinical use since 2009 and is subject to continuous further development. Through close cooperation with the IT department, all examination devices could be digitally connected, enabling paperless work and avoiding the drawbacks of paper files.

DISCUSSION

The advantages of an EHR implemented into the existing HIS are manifold. Through such a system a complete, interdisciplinary and ubiquitous documentation can take place. The alternative is the acquisition of a third system, which must be connected by an interface with the main system and has significantly higher acquisition and maintenance costs.

摘要

背景

对许多医院而言,在眼科领域实施电子病历(EHR)系统可能是一项具有挑战性的项目。尽管所有医院都有医院信息系统(HIS),但这些系统往往无法处理眼科患者记录的复杂性。

方法

本文报告了将眼科电子病历实施到现有的医院信息系统(爱克发ORBIS;德国波恩爱克发医疗保健有限公司)中的情况。介绍了数字记录管理以及与周边检查设备的连接。

结果

我们开发的电子病历自2009年起已投入临床使用,并在持续进一步发展。通过与信息技术部门密切合作,所有检查设备都能实现数字连接,实现无纸化工作并避免纸质文件的弊端。

讨论

在现有医院信息系统中实施电子病历的优点众多。通过这样一个系统,可以进行完整、跨学科且无处不在的记录。另一种选择是购置第三个系统,该系统必须通过接口与主系统连接,且购置和维护成本显著更高。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/44e4/7544718/3c79681c037a/347_2020_1048_Fig1_HTML.jpg

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