电子健康记录(EHR)

Tom Seymour, Dean A. Frantsvog, T. Graeber
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引用次数: 35

摘要

电子健康记录是患者医疗记录的电子版本。电子健康记录以电子方式收集、创建和存储健康记录。医疗保健提供者采用电子健康记录的速度很慢。联邦政府最近通过立法,要求使用电子记录,否则将面临罚款。电子健康记录将改善临床文档、质量、医疗保健利用跟踪、计费和编码,并使健康记录具有可移植性。电子健康记录的核心组件包括管理功能、计算机化医嘱输入、实验室系统、放射学系统、药房系统和临床文件。HL7是电子健康记录使用的标准通信协议技术。软件、硬件和IT网络的实现对于成功的电子健康记录项目非常重要。电子健康记录的好处包括提高医疗效率、大幅提高质量和安全性,以及降低消费者的医疗成本。电子健康记录面临的挑战包括昂贵的软件包、系统安全性、患者机密性和未知的未来政府法规。未来的电子健康记录技术包括条形码、射频识别和语音识别。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Electronic Health Records (EHR)
Electronic Health Records are electronic versions of patients’ healthcare records. An electronic health record gathers, creates, and stores the health record electronically. The electronic health record has been slow to be adopted by healthcare providers. The federal government has recently passed legislation requiring the use of electronic records or face monetary penalties. The electronic health record will improve clinical documentation, quality, healthcare utilization tracking, billing and coding, and make health records portable. The core components of an electronic health record include administrative functions, computerized physician order entry, lab systems, radiology systems, pharmacy systems, and clinical documentation. HL7 is the standard communication protocol technology that an electronic health record utilizes. Implementation of software, hardware, and IT networks are important for a successful electronic health record project. The benefits of an electronic health record include a gain in healthcare efficiencies, large gains in quality and safety, and lower healthcare costs for consumers. Electronic health record challenges include costly software packages, system security, patient confidentiality, and unknown future government regulations. Future technologies for electronic health records include bar coding, radio-frequency identification, and speech recognition.
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