如何成功導入電子病歷系統：醫院的觀點

How to Adopt Electronic Medical Records Successfully: Hospital Perspectives

郭光明(Kuang-Ming Kuo) ； 佘明玲(Ming-Ling Sher) ； 黃興進(Hsin-Ginn Hwang)

《病歷資訊管理》 9卷2期 (2010/06) Pp. 19-36

https://doi.org/10.29741/JMHIM.201006.0002

摘要

「病歷」是醫療人員從事醫療行爲的主要紀錄，也是輔助臨床決策重要資訊來源。傳統紙本病歷面臨許多挑戰與問題，隨資訊科技發展，將傳統書面病歷紀錄電腦化之「電子病歷」觀念因運而生，從紙本病歷到電子病歷可視爲典範轉移。電子病歷除解決醫師手寫辨識不易、紙本病歷保管、使用及空間問題外，也可提升醫療服務品質及加速申請給付效率。近年來衛生署已花費相當大的努力推動醫院採用電子病歷，而醫院要能夠成功採用電子病歷，管理高層必須改善對於電子病歷的瞭解程度。本論文整合國內外推動電子病歷經驗，彙總相關研究結論，從醫院觀點提出電子病歷授用模式及相關建議，期望能提供政府衛生主管單位在擬定及推動圈內電子病歷相關政策的參考。

關鍵字

病歷 ； 電子病歷 ； 電子病歷採用

並列摘要

Medical records are generated when members of medical staff are engaged in treating patients, and such records are important sources of supplementary information for later-on clinical decision-making. Traditional medical records on paper have been faced with many challenges and caused many problems. With new advances in information technology, a concept of ”Electronic Medical Records (EMR),” which computerizes and transforms the old paper-type medical records into new electronic ones is proposed and recognized as a significant paradigm shift. Other than being a great help in solving problems such as not-recognizable handwritings and limitations in the records' keeping, utility, and storage space, the adoption of EMR is also able to improve the overall quality of medical services offered and accelerate the process of reimbursement application In recent years, Department of Health, the government health authority of Taiwan, has made a lot of efforts to persuade hospitals to adopt EMR. In order to be successful in the adoption, top officers of the hospital management must upgrade their understanding of EMR. Based on a study of domestic and international experiences of adopting EMR and other related issues, this paper proposes a workable model and relevant suggestions, which can be used as a reference for the government health authority to formulate needed policies for promoting EMR in Taiwan.

並列關鍵字

Medical Records ； Electronic Medical Records EMR ； EMR Adoption