Rind D M, Safran C
Center for Clinical Computing, Harvard Medical School, Boston, MA.
Proc Annu Symp Comput Appl Med Care. 1993:74-8.
We developed an electronic medical record for ambulatory patients as part of the integrated clinical information system at Beth Israel Hospital. During the four years since it was installed, clinicians have entered 76,060 patient problems, 137,713 medications, and 33,938 notes. Residents, who had to type notes in themselves, entered 49.5% of their notes into OMR. Several factors that we had predicted would be barriers to an electronic medical record, such as clinician reluctance to type or perform data entry, have not proved to be significant problems. Other anticipated barriers, such as difficulties with dual charting on paper during transition to an electronic medical record, have been realized. The major unexpected barrier that has been encountered is increased clinician concern about the privacy and security of full text notes relative to other data elements in the clinical information system. We have attempted to modify the electronic medical record so as to overcome some of these barriers.
作为贝斯以色列医院综合临床信息系统的一部分，我们为门诊患者开发了一份电子病历。自安装以来的四年里，临床医生录入了76060个患者问题、137713种药物以及33938条记录。必须自行录入记录的住院医生将49.5%的记录录入了OMR。我们曾预测会成为电子病历障碍的几个因素，比如临床医生不愿打字或进行数据录入，并未证明是重大问题。其他预期的障碍，比如在向电子病历过渡期间纸质双份记录的困难，已经出现。所遇到的主要意外障碍是，与临床信息系统中的其他数据元素相比，临床医生对全文记录的隐私和安全性更加担忧。我们已尝试修改电子病历以克服其中一些障碍。
