Dujat C, Haux R, Schmucker P, Winter A
University of Heidelberg, Department of Medical Informatics, Germany.
Methods Inf Med. 1995 Dec;34(5):489-97.
The large number of inpatients and outpatients in university hospitals leads to high costs of medical documentation and to an increasing number of medical documents. Due to legal regulations, these medical records have to be stored for 30 years. This implies spatial, organizational, and economical problems. At present, conventional archiving in hospitals often does not satisfy the need to make medical records available for health-care professionals in a systematic and timely manner. From 1989 to 1993 a pilot study on "digital optical archiving of medical records" was carried out at Heidelberg University Hospital. The study has shown the feasibility of digital optical archiving in hospital s if done under certain conditions. In 1995, Heidelberg University Hospital adopted a procedure for "digital optical archiving of medical records". The digital optical archive will first be filled with the medical records of the department of neurosurgery and the endoscopic and echographic images and reports of the department of internal medicine. It is to be expected that this procedure will gradually lead to an integrated functionality on health-care professional workstations, to a hospital-wide use of an electronic patient record, and to media-independent document management systems. The paper focuses on the potentials of digital optical archiving as an integral part of hospital information systems, and on the requirements for the systematic managements of hospital information systems with respect to digital optical archives.
大学医院大量的住院和门诊病人导致医疗文档成本高昂,且医疗文档数量不断增加。由于法律法规要求,这些医疗记录必须保存30年。这带来了空间、组织和经济方面的问题。目前,医院传统的存档方式往往无法满足医护人员系统、及时获取医疗记录的需求。1989年至1993年,海德堡大学医院开展了一项关于“医疗记录数字光学存档”的试点研究。研究表明,在特定条件下,医院进行数字光学存档是可行的。1995年,海德堡大学医院采用了“医疗记录数字光学存档”程序。数字光学档案馆将首先存入神经外科的医疗记录以及内科的内镜和超声图像及报告。预计该程序将逐步实现医护人员工作站的集成功能、全院范围使用电子病历以及与介质无关的文档管理系统。本文重点探讨数字光学存档作为医院信息系统不可或缺的一部分的潜力,以及医院信息系统在数字光学档案方面的系统管理要求。