档案视角下电子病历管理的问题与对策

Problems and countermeasures of electronic medical record management from the perspective of archives

我国医院电子病历档案一般由病案室管理,接受卫生主管部门的监督与指导,易出现电子病历档案属性弱化的情况。对某地级市的三家三级医院进行问卷调查发现,病案室档案学与计算机相关专业人员占比极低,电子病历主要作为业务数据使用与管理,在档案的真实性、完整性、可用性上关注不足。建议从优化档案管理团队人员结构、加强元数据管理、应用数字签名、推进单套制等方面提升电子病历档案管理的专业性。

The electronic medical record archives of hospitals in China are generally managed by the medical record room,supervised and guided by the competent health department.The attribute of the electronic medical record archives is easily weakened.A questionnaire survey was conducted in three tertiary hospitals in a prefecture level city.It was found that the proportion of professionals in archival science and computer related professional background in the medical record room was very small.Mainly used and managed as the business data,electronic medical records were paid attention insufficiently in authenticity,integrity and availability of archives.It was suggested to improve the professionalism of EMR file management from the aspects of optimizing the composition of management team,strengthening metadata management,applying digital signature and promoting single set system.