医院开展病案无纸化归档系统建设的思考

Construction of Hospital Medical Record Paperless Filing System

医院病案管理始终被高成本、低效率、难共享、轻利用等问题困扰,病案归档迟迟未能突破传统的纸质病案管理模式。随着医疗信息技术的发展,病案无纸化归档成为未来发展趋势。医院开展病案无纸化归档建设面临法律认可、基础评估及流程重塑三大关键性问题,完整的病案无纸化归档系统应该具备五种能力,即临床信息系统的集成整合能力、非临床信息系统文档的无纸化能力、高可靠及高效检索的存储能力、人机互动的智能质控能力、数据的再利用能力。无纸化病案库将为建设居民电子健康档案库、实现区域化医疗提供基础,良好的共享能力也将为分级诊疗提供有效支持,其建设意义重大。

High cost,low efficiency,sharing difficulty and low-efficient utilization are current drawbacks for medical record management.With the development of medical information technology,the implement of medical record paperless archiving has become a development trend.In this paper,we discuss three key issues,legitimacy,basic evaluation and process reconstruction,which are involved in the construction of medical record paperless archiving system.Moreover,a perfect medical record paperless archiving system should have five types of functions,namely integration to the clinical information system,paperless documentation for information other than those from the clinical information system,reliable and large storage to offer efficient retrieval,smart quality control based on the human-computer interaction,and data reuse.It provides reference for hospitals to carry out the medical record paperless archiving system construction.