电子病历——医院信息化建设的核心

Electronic medical record:the pivot of hospital it construction

随着医学诊断技术的飞速发展和电子信息技术在医疗领域的广泛应用,医院信息系统已从最早的以收费管理为中心的管理信息系统,到以病人医疗为中心的业务支持系统,即用电子设备书写、保存、管理、传输、重现的数字化的病人诊疗记录。谨就电子病历的概念、发展现状、电子病历应涵盖的内容、电子病历结构、存在问题及电子病历相关法律技术等问题,简述如下。

With the rapid development of medical diagnostic technology and extensive application of electronic information technology in the medical field, the hospital IT system has developed from the accounting-centered to the medical affair-centered one, a system that records, stores, manages, transmits and displays digitalized medical records by electronic equipment. This paper presents a brief review of the concept, the current development, the coverage and the structure of electronic medical record, along with its existing problems, especially those related with laws.