Electronic medical records, I want to say that sharing is not easy

Electronic medical records, I want to say that sharing is not easy

Technology Daily Li Ying

People who visit the doctor must be familiar with the computer and printer on the doctor’s desk. The patient’s condition no longer needs doctor’s handwriting. The doctor will be based on the patient’s Oral, enter information into the computer. With the medical record printed in an instant, the patient is no longer guilty of not being able to understand the “” handwritten by the doctor.

Electronic medical records are favored by hospitals and doctors, and their advantages are unquestionable. In China, multiple voices call for the interconnection of electronic medical records in hospitals, to achieve patient diagnosis information sharing, to avoid repeated inspections, to reduce medical expenses, and to assist in grading diagnosis and treatment. Even the former US President George W. Bush and Obama have promoted it, saying that electronic medical records can avoid medical errors, reduce costs, and improve service quality.

electronic medical record, want to say sharing is not easy

However, with the popularity of electronic medical records, its drawbacks are increasingly apparent. Recently, it has been reported that the largest medical dispute insurer survey in the United States shows that many medical disputes involve electronic medical records. From June 2014 to December 2016, 66 medical disputes involved electronic medical records, and between 2007 and 2010, only There are 2 cases.

Is the electronic medical record breaking the information island? Are the electronic medical records of all hospitals interconnected? How can we better use electronic medical records to serve patients? With all kinds of questions, the reporter visited Liu Yuhong, director of the Information Department of Beijing Chaoyang Hospital.

Electronic medical records

are an integral part of the information system

Although electronic medical records have been used in the United States for a decade or two, they are still relevant. The agency accused that the system is not sound. The problem is concentrated in the following: lack of integration of hospital electronic medical records, no warning early warning function, lack of interoperability of the system. Among them, the lack of interoperability of the system is the most serious, and it is impossible for medical institutions to share and integrate patient information for care coordination. Although the US government has developed a blueprint for enhanced interoperability, implementation is not ideal.

In this regard, Liu Yuhong said, “The system is always updated. At present, our understanding of electronic medical records is somewhat narrow, and there is no consensus on the concept of electronic medical records.” /p>

The so-called electronic medical record refers to the digital medical service work record of the medical institution for clinical diagnosis and guidance intervention of outpatients, inpatients (or health care subjects), and is the process of individual residents in the medical institutions. Complete and detailed clinical information resources generated and recorded. “Electronic medical records not only refer to static medical record information, but also related services provided.” Liu Yuhong further explained that electronic medical records are not equivalent to “hospital information systems”, and it focuses on individuals who are involved in the process of receiving various medical services from medical institutions. The data integration system for clinical diagnosis and guidance intervention information is an integral part of the “Hospital Information System”. In addition, from the perspective of technological development and application content, the electronic medical record should have three connotations: one is to include the complete information of the patient and can be shared; the second is to provide medical tips and alarms; the third is to provide database support.

“For example, the “Healthy Cloud” recently launched by Chaoyang Hospital.” Liu Yuhong revealed that patients only need to install the client through the mobile phone and move their fingers to see the press. The order of medical treatment, sorted out the medical information and the information of each department, doctor, diagnosis, prescription, etc., can also check the X-ray, B-ultrasound, CT and other inspection reports.

Electronic medical records

Supervisory management loopholes

The advantages of electronic medical records are obvious, but patients also have concerns about the protection of the right to know and privacy. Once a information leak leads to a dispute, it is a terrible thing.

There were thousands of maternal personal information leaked from the Shenzhen Maternal and Child Health Hospital. The information was even detailed to the gestational age and expected date of birth, residential address, telephone number, etc. Although the police arrested two suspects for allegedly infringing on the personal information of citizens, the public was very worried about the disclosure of their information, especially the disclosure of patient information.

Citizens’ personal information security and patient privacy cannot be insulated from the era of big data. Liu Yuhong believes that in order to prevent information from being leaked and abused, the key is to have sound laws and systems, and to have reliable remedies, that is, to improve the protection mechanism of hospitals and health systems for patients’ medical records and information. In addition, at the beginning of the development of application software, patient privacy protection and data security are designed as the primary technical elements.

“The establishment of an electronic medical record quality control system is an effective way to ensure the quality of electronic medical records.” Liu Yuhong stressed that electronic medical records as an important part of hospital information management, in addition to technical and operational Procedural checks, relevant government departments should develop relevant electronic medical record management policies based on the management of traditional medical records, and the relevant government departments through these systems to strengthen the management of electronic medical records security.

It is understood that the current hospital’s protection of electronic medical records and electronic health records relies mainly on industry self-discipline. The health department has promulgated the “Guiding Opinions on the Protection of Information Security Levels in the Health Industry”, but only specifies the level of hospital information protection, and there are no specific measures to regulate the patient’s medical records. In this regard, Zeng Qiyi, dean of Zhujiang Hospital of Southern Medical University, believes that in addition to enacting relevant laws and regulations to protect the legitimate rights and interests of patients, there must be a mechanism of severe punishment. Only by letting people who violate laws and regulations pay a heavy price can this behavior be eliminated. .

Lack of demand? Lack of motivation?

The lack of mechanism breakthrough?

At present, many hospital electronic medical records have not yet been interconnected. Patients have been treated in a certain hospital and some basic tests have been done. However, when they want to go to another hospital to see a doctor, they are often required to be in this hospital. double check. Such repeated examinations increase the patient’s troubles, increase the economic burden, and are not conducive to the promotion of graded diagnosis and treatment.

Promoting the sharing of medical records and realizing the sharing of information such as tests, imaging, and diagnosis of patients’ visits is a great matter for the convenience of the people. Liu Yuhong said that the “healthy cloud” includes all the patient information in the Chaoyang Hospital. Patients can check medical records, prescriptions and other medical information without going to and from the hospital, saving time and transportation costs, and avoiding loss of laboratory reports. And the situation that the medical information is incomplete.

The ideal is full, but the reality is not optimistic. It is known that not all hospitals can share information at present. For this, Qi Wensheng, director of the Information Center of the Beijing Municipal Health and Family Planning Commission, said that first of all, doctors lack the rigidity of electronic health record sharing needs, and did not see other hospital information. In the case, the patient can be diagnosed. Secondly, the hospital lacks motivation and information can be shared, but it may not be shared because it is linked to the economy. In addition, there is a lack of institutional design in policy and a lack of mechanism for construction.

electronic medical record, want to say sharing is not easy

In Beijing, for example, in 2011, Beijing implemented the “Medical Union Code”, and patients can use only one medical card in all tertiary hospitals in Beijing. Although the wish is very good, the project has not been interconnected, so the project has been slow to advance; in 2012, the Beijing Municipal Health Bureau, the Municipal Hospital Administration and the Bank of Beijing jointly launched the “Jing Yi Tong”, and the patients can complete the online on the mobile phone. Registration, payment function, eliminating the need to line up the line. After the implementation of the medical reform, “Jingyitong” basically landed; in 2015, the Beijing Municipal Health Planning Commission launched the “Beijing Tong” resident health card to realize the real “one card” for medical treatment. In the future, “Jingyitong” is very likely and “Beijing” “Combination” is integrated.

No matter which government department implements which card, each hospital needs to change the status quo of system independence and build a unified digital exchange system at the upper level. Although there are policy requirements and requirements for medical reform, there are still many limitations in sharing and reviewing electronic health records, not just the technical department. Only when the management department, especially the fee payer, promotes it together can make a big breakthrough. So there is still a lot of work to be done to achieve the goal, and there is still a long way to go.

The pictures in the text are from the network except the ones indicated