McDonald C J
Regenstrief Institute for Health Care; Indiana University School of Medicine, Indianapolis, USA.
J Am Med Inform Assoc. 1997 May-Jun;4(3):213-21. doi: 10.1136/jamia.1997.0040213.
Institutions all want electronic medical record (EMR) systems. They want them to solve their record movement problems, to improve the quality and coherence of the care process, to automate guidelines and care pathways to assist clinical research, outcomes management, and process improvement. EMRs are very difficult to construct because the existing electronic data sources, e.g., laboratory systems, pharmacy systems, and physician dictation systems, reside on many isolated islands with differing structures, differing levels of granularity, and different code systems. To accelerate EMR deployment we need to focus on the interfaces instead of the EMR system. We have the interface solutions in the form of standards: IP, HL7/ASTM, DICOM, LOINC, SNOMED, and others developed by the medical informatics community. We just have to embrace them. One remaining problem is the efficient capture of physician information in a coded form. Research is still needed to solve this last problem.
各机构都想要电子病历（EMR）系统。他们希望这些系统能解决病历流转问题，提高医疗过程的质量和连贯性，使指南和医疗路径自动化，以辅助临床研究、结果管理和流程改进。电子病历很难构建，因为现有的电子数据源，如实验室系统、药房系统和医生口述系统，存在于许多孤立的“岛屿”上，其结构不同、粒度级别不同且代码系统也不同。为了加速电子病历的部署，我们需要关注接口而非电子病历系统。我们有以标准形式存在的接口解决方案：IP、HL7/ASTM、DICOM、LOINC、SNOMED以及医学信息学界开发的其他标准。我们只需接纳它们。剩下的一个问题是以编码形式高效获取医生信息。仍需开展研究来解决这最后一个问题。
