电子病历的应用、问题及未来发展

Application of Electronic Medical Record and its Problems and Future Development

目的:论述基于XML的电子病历的应用情况以及存在的问题和不足,探讨电子病历的未来发展和需求。方法:对近3a来XML电子病历在我院的实际应用经验和电子病历的发展现状进行总结。结果:目前的XML电子病历为病历的书写和医疗质量监控提供了极大的便利,但仍存在着一些问题和不足。结论:电子病历作为临床信息系统(CIS)的重要组成部分,已经成为医院信息化进程中必不可少的一部分,但其广泛应用仍任重道远。

Objective To describe the application situation, existent problems and insufficiencies of the electronic medical record （EMR） based on XML, and discuss the future development and requirement of EMR. Methods In recent three years, the application practice and current development condition of EMR based on XML were summarized. Results The EMR based on XML was provided considerable convenience and advantage for writing of medical record and the monitor of medical quality. Conclusion The electronic medical records are an important part of client information system （CIS）, his become a necessary part of hospital informationization, and its extensive application has a long way to go. [Chinese Medical Equipment Journal,2009,30（3）：49-50]