电子病历概念参考

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CPR
The Computer-based Patient Record was the term used in the report of the Institute of Medicine. The report recommended that an Institute be formed to promote and develop standards for the CPR. This Institute, the Computer-based Patient Record Institute (CPRI) played during its 10-year existence a major role in promoting the vision during its 10-year existence.
"The electronic health record is a computer-stored collection of health information about one person linked by a person identifier."i This statement encompasses the fundamental vision of the computer-based patient record. The vision for the CPR encompasses a mainly virtual computer-based medical record that includes all information (clinical and administrative) and covers all practitioners ever involved in a person\'s health care, independent of medical specialties. Therefore, it includes linked bits and pieces of a person\'s health history from the dentist to the psychiatrist. It also is longitudinal, ideally including prenatal and postmortem information. The CPR vision also had an important feature as it foresaw the CPR as a basis for and an integral part of decision support. In other words, it distinguished the CPR from the paper-based medical record, which was a passive recording tool.
Objections
The vision of a longitudinal health record has become controversial in regard to confidentiality. The notion that the computer-based patient record should include everything from pre-natal to post-mortem information has been rebuffed by privacy advocates. When I testified to a Senate committee in 1996, I was told by a very famous politician, "I am 64 years old. I do not want my physician to know whether I had a mental breakdown at 16, or an abortion at 19. It does not affect my care now and I resent any plans for a lifelong health record." Privacy advocates have argued that in the majority of cases, the medical record should only contain information that is relevant to care regarding a specific encounter. Of course, in cases of chronic illness, there may be exceptions. The discussion of what is relevant has not come to any conclusion. Researchers, of course, would like to work with all information of lifetime records. Practitioners have mixed responses ("too much irrelevant information","would never look at it", "might be useful"), but privacy advocates have been rejecting the idea, except when there is a special medical reason to link such information.
The vision of an interoperable patient record that is provider independent is unrealistic. There is neither incentive, nor technical possibility in the foreseeable future, for a medical record that is interoperable between unlimited provider entities.
There was no benefits justification. The CPR was to bring better care and/or make the system more efficient. The latter has not been demonstrated yet. It is widely accepted that using the computer means slower data entry for the practitioner. Why should providers spend money for such systems? Outside of a few medical centers, where installations were driven by individuals, the CPR never got into the mainstream of healthcare provider implementations.
Practitioners could not be convinced to use computers in the exam room when there were difficulties in justifying costs, essential training resources, and necessary system changes. This should not be mistaken for some of the products labeled “CPR Systems.” Many systems do not comply with the criteria for a CPR and are just good marketing.
Many vendors identified their products as CPR systems, although none satisfied the requirements for a longitudinal, completely paperless, interoperable, multi-
provider-, and multi-discipline-based computer-based medical record. The benefits of CPR systems were generally accepted to be "better quality of care" and "higher efficiency."
In summary, the CPR vision is diminished by the following issues:
• Privacy issues resulting from the vision of a lifetime record that will follow the patient
• Unrealistic expectations for interoperability
• Lack of benefits and incentives
By 1995 most people recognized the discrepancy between the vision and the reality. Standards, workflow, and user habits, as well as technologies weren\'t ready for the grand vision originally put forward. Most of all, the business case for CPRs was difficult to achieve. Hopes for many of the hyped new technologies, such as speech recognition and community health information networks, fizzled while traditional information systems grew enormously. Transcription, for example grew during the last decade to an estimated $15- billion to $20 billion industry, involving 300,000 to 400,000 medical transcriptionists.
The term CPR continues to be used by many of the individuals involved in the CPRI as well as in circles of the American Medical Informatics Association and their international affiliates.

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Patient-carried Medical Record
During the mid 1980s, long before the CPR became fashionable, the vision of patients being in charge of their health information became a leading force. The vision was based on a patient being the connecting entity for all health information. If one would give the patient his health information on a device, he could then bring it with him to providers, thus guaranteeing continuity of care. The practical solution was a patient card in the form of a smart card (with a computer chip) or a card using another technology such as optical stripes, magnetic high density stripes, 3-dimensinal bar codes, etc. Some of these cards can have a capacity of several megabytes, enabling them to become health passports. The concept actually is in use with many providers such as the Veterans Administration Health System, where patients carry their own health records (but not cards, of course).
By the late 1980s this vision failed because of technical card problems, issues with capacities, difficulties with interoperability concerning content and terminology, but most of all due to lack of an infrastructure that allows every provider to record and read cards, even if they were motivated to spend extra time and resources for this exercise. This failed vision did cost an estimated $500 million to the healthcare industry. Today, there are some related approaches by some healthcare providers. For instance, some European providers give upon discharge their private patients a CD ROM with all their patient information.

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Computerized Medical Record (CMR)
Most of the versions of electronic health records require a change in practitioners\' documentation habits from easy handwriting or dictation to computer input. Even more, they require standards in interoperability as well as in the areas of security and authentication. While a consensus on such standards is still lacking, many providers are looking for alternatives.
Document imaging represents the computerized medical record (CMR). Document imaging involves prepping, scanning/digitizing, indexing, and performing quality control of traditionally recorded paper documents into a computer system. Analog paper documents, either created through handwriting or transcription can be transferred into digital form with image scanning, optical character recognition (OCR) scanning, or hybrid systems of these. This has the advantage that patient information even when created in paper format is shareable within an organization. It also has the benefit of guaranteeing a higher level of document integrity than found in many current computer systems in regard to signature, persistence in storage, and other integrity features. Document imaging allows the reader to view the information only as a complete image. Optical character recognition, in which the text is scanned/digitized line by line, has recognition and authentication problems, so it is very rarely used and is costly.
CMR is a passive computer recording. More than 1,500 installations have been reported during the last 14 years, many with mixed success. In general CMR applications can be viewed as successful in specialized settings where workflow is altered, and the benefits of having an electronic image of documents outweighs the disadvantages. The CMR is not a “natural stepping stone” to other EHR applications.

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Electronic Patient Record (EPR)
The electronic patient record concept grew out of the CPR concept and, for a while, was the dominant term used. Some observers considered this term synonymous to the CPR term" however, an increasing number of individuals stated that the EPR vision differs from the CPR vision in the following:
• EPR is a collective vision of many systems and components which that are part of this overall concept.
• EPR is derived of all “relevant” patient information. As the relevancy differs from case to case, it is mainly driven by software. For instance, “normal” results may not be stored. However, those data that influence the care process will be part of the EPR.
It is recognized that a patient-centered electronic patient record has the same requirements regarding interoperability that are difficult to satisfy. In general, the term EPR is a term that is less used than others, particularly the term EHR.

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Electronic Medical Record (EMR)
When one looks at the interoperability requirements of both the CPR and the EPR as they would be expressed in complete interoperability between information systems in varying locations, challenging provider settings, and different infrastructures, a realistic approach seems to be more reasonable. This is the electronic medical record, an electronic healthcare information system regarding one patient within an enterprise. Clearly, the goal for many providers is to create complete interoperability among the departmental systems. An enterprise may be a clinic, hospital, health plan, or (in Europe, for instance) a health authority. It seems to be a reasonable goal to harmonize incompatible, disparate systems into a comprehensive electronic medical record that includes all documentation of care given to a specific patient within the enterprise. The EMR can be used as a natural steppingstone stone toward an EPR, DMR, or EHR.

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Digital Medical Record (DMR)
The digital medical record is a less-known term that represents a vision of web-based medical records that are not based on push technology but on pull technology. Its vision is based on an XML-based generic standard that allows communication as well as data management based on this one standard. The vision calls for patient information to be posted on the website site of a provider or health plan. Information is accessed by practitioners rather than sent as messages. The DMR can have the functionality of the EMR, EPR, or EHR.
Patient Medical Record Information (PMRI)
The term PMRI became popular because it is used in HIPAA legislation. It is being used by the National Committee for Vital and Health Statistics (NCVHS). The term was put forward as a synonym for the EHR and does not define an entity (such as record) in a central or virtual location. Rather, it addresses the current state, i.e." bits and pieces of a patient\'s health information form various records.

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Electronic Health Record (EHR)
The term electronic health record now has dual meaning. For one, it is used by the majority of people as a generic term for an electronic version of the medical record and/or any of the concepts described above. In addition, the term EHR stands for a particular concept, - one that is different from all others. The EHR is different from the
• CPR, as it does not necessarily containing all information from pre-natal to postmortem information but focuses on relevant information for current or future care. It also consists of components that are implemented according to measurable, realistic benefits. Finally, its vision includes wellness, alternative healthcare documentation as well as information of the personal health record.
• CMR as it is not an image but a digital record that can be used in decision support applications as well as for interactive recording.
• EMR, as it is not limited to a healthcare enterprise.
• DMR, as it is integrating legacy systems and traditional database and messaging systems.
• PHR, as it primarily created and managed by providers and practitioners.
Its unique roles are:
  It represents a provider-based view of that patient\'s health history.
  It provides a method for clinical communication and care planning among the individual healthcare practitioners serving the patient. The decision-making process related to care given provided (or not provided) and care actions delayed for insurance or organizational reasons are part of this medical record.
  It is important in documenting the specific services received by the patient for reimbursement purposes.
  It serves as the legal document describing the healthcare services provided
  It is a source of data for clinical, health services, outcomes research, and public health.
  It serves as a major resource for healthcare practitioner education.
  It is easily shareable among authorized practitioners.
  It encourages interactive recording at the Point-of-Care.
  It is the basis for decision support.