关于电子病历的探讨（国外精华文章探悉）

逍遥侠 · 发表于 2006-4-9 10:14:13

<img src="http://bbs.miforum.net/images/smiles/smile.gif" border="0" onclick="javascript:window.open(this.src);" alt="" style="CURSOR: pointer" onload="javascript:if(this.width>screen.width-500)this.style.width=screen.width-500;" /> 今天看了一篇国外文献，关于病历的书写格式探讨，感觉很新鲜。特转发。Leveraging（杠杆作用） systems thinking to design patient-centered clinical documentation systems Adam S. Rothschilda, Linda Dietrichb, Marion J. Ball b,c,∗, Heidi Wurtzb, Holly Farish-Huntb, Nhora Cortes-Comererb a Department of Biomedical Informatics, Columbia University, New York, NY, USA b Healthlink Incorporated, Houston, TX, USA c Johns Hopkins School of Nursing, 5706 Coley Court, Baltimore, MD 21210, USA Received 29 June 2004;received in revised form 23 March 2005;accepted 23 March 2005 本文是美国哥伦比亚大学的生物信息研究所教授所写。文章阐述了以病人为中心的临床文档系统的设计思路，初看此文好像是一位护理人员所写，通过进一步研究，发现论述的不是一种病历的书写过程，而是哪一种病历的书写更适合于电子病历的研发。以下是文章的摘要及部分相关内容： Summary A hospital is a type of system, yet healthcare information technology (IT) has largely failed to view it as such. The failure to view the hospital as a system has contributed to the practice of inefﬁcient and ineffective clinical documentation. This paper seeks to address how current clinical documentation practices reﬂect and reinforce inefﬁciency and poor patient care. It also addresses how rethinking clinical documentation and IT together may improve the entire healthcare process by promoting a more integrated and patient-centered healthcare information paradigm. Rethinking IT in support of clinical documentation from a system-oriented perspective may help improve patient care and provider communication. 我认为的论文精华内容： Our approach, called the problem-driven health record (PDHR), is similar to the POMR （problem-oriented medical record) in that the problem list also plays a central role. It is different, however, in three major ways. First, the

DHR paradigm is not nearly as strict as the POMR paradigm. In the strict POMR, a separate progress note in the ubjective—objective-assessment-plan (SOAP) format is written for each problem, and information that is relevant to more than one problem is recorded redundantly. The PDHR does not require this redundant recording of information. Second, the PDHR is designed to be implemented in an EHR rather than on paper. It is designed to integrate other traditionally distinct) EHR activities, such as order entry and results review, into the documentation process. Third, it utilizes a controlled medical terminology (CMT) with which to record problems. Using a CMT enables easy downstream reuse of problem data for many purposes such as triggering problem-speci.c decision support rules and aiding in reimbursement, research, operations management, and public health reporting.

medsoft · 发表于 2006-4-9 13:26:13

problem-driven health record (PDHR)，很好，我跟几个人私下谈过，我们现在的研究重点就是事件驱动型电子病历，Event-driven health record (EDHR), 说起来，可能会异曲同工！欢迎加入<a href="http://www.china-ehr.com/" target="_blank">电子病历研究中心</a>，共同进一步探讨！ <div>此帖由 medsoft 在 2006-04-09 14:12 进行编辑...</div>

ironstone · 发表于 2006-4-11 11:40:27

OMR在国外已经有很长时间的应用,已经形成一套比较完整的体系,包括其理论基础,其表达方式和书写要求(SOAP),以前研究医生工作平台的时候,对这方面有所涉及,了解一点.不过要说到PDHR可能还需要更长的时间来积累.对于电子病历,我觉得在目前阶段都是处于一种电子化的阶段,即采用电子手段来实现手工书写的东西,很多人在对电子病历进行定义,其实我觉得这是没必要的,等到真正到全部电子化之后,电子病历是不是还是我们现在所想象的,是否会有新的表现方式,

小城医生 · 发表于 2006-4-11 12:20:41

是技术引导消费？！

medsoft · 发表于 2006-4-12 09:13:35

Event-driven health record (EDHR)事件驱动型电子病历有望发展成为一种新的电子病历架构，而不会仅限于文本内容方面，这方面跟problem-driven health record 有很大的不同。事件驱动与软件开发的结合非常紧密，甚至在解决电子病历的安全方面有一些很有意思的地方。

43sunset · 发表于 2006-6-13 14:16:49

听起来让人激动

lovelybabyli · 发表于 2006-8-17 15:41:58

请问能否把原文上传，急需，多谢

逍遥侠 · 发表于 2006-8-24 21:06:56

<img src="http://bbs.miforum.net/images/smiles/tongue-out.gif" border="0" onclick="javascript:window.open(this.src);" alt="" style="CURSOR: pointer" onload="javascript:if(this.width>screen.width-500)this.style.width=screen.width-500;" /> 很抱歉，这篇文章的原文被我删除了。如果找到再传了你检索一下SDOS数据库看一下了

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