电子病历实施过程中的法律风险及应对策略研究

Study on the legal risks in the implementation of electronic medical records and its countermeasures

目的探讨电子病历在实际应用过程中存在的法律风险并探讨相应的解决策略。方法通过文献法将影响电子病历法律效力存在的问题重点进行归类总结,并结合调查问卷及访谈法进行现场调研。结果电子病历最受关注的潜在风险为修改问题,其电子签名可靠性、电子病历的安全性、医患关系以及监督部门等均为影响电子病历法律效应的重要问题。结论电子病历的法律风险应从物质基础、概念意识和外围环境等方面加以改善。

Objective To explore the legal risks in the application of electronic medical record( EMR)and explore the corresponding solutions.Methods The existing problems affecting the legal validity of electronic medical record were classified and summarized by literature method,and the field investigation was carried out by questionnaire and interview. Results The potential risk of electronic medical record was revision. The reliability of electronic signature,the security of electronic medical record,the relationship between doctors and patients,and the supervision department were all important issues affecting the legal effect of electronic medical record.Conclusions The legal effect of electronic medical record should be improved from the aspects of material basis,concept consciousness and external environment.