跨越病歷資訊管理新時代－談紙本病歷數位化之策略

Striding across a New Health Information Management Era-Strategies of Digitalizing Paper-based Medical Records

莊靜薇(Chin-Wei Chuang) ； 范碧玉(Bih-Yuh Fan) ； 楊銘欽(Ming-Chin Yang)

《病歷資訊管理》 9卷2期 (2010/06) Pp. 72-83

https://doi.org/10.29741/JMHIM.201006.0005

摘要

病歷資訊管理時代的來臨，象徵一個嶄新時代的開始。然而在醫院進行資訊化過程中仍保有大量的紙本病歷運行著，面對電子病歷新時代，過去的紙本病歷包袱沉重，這些紙本病歷佔用龐大空間、耗費人力並且無法永久保存。要如何進行大量紙本病歷數位化成爲一大課題。
本文著重病歷數位化議題深入討論，此議題探討不能僅僅由成本效益的角度切入，必須同時考量各年度病歷總量估計、病歷保存期限、病歷調閱頻率綜合分析。
本文分爲紙本病歷概述、病歷保存量估計、實證研究三大部份介紹。從紙本病歷基本定義、活動病是與不活動病歷開始介紹，進而同時考量各年度病歷總量估計可以讓我們知道各年度共有多少病歷量產生，以方便進行連續性的成本估算；而病歷保存期限方面，目前世界各國訂立法規皆不相同，台灣根據醫療法第七十條規定病歷至少需保存7年，然而各醫院可綜合考量教學、教育、健康保險制度需求等等原因，決定各院紙本病歷保存年限；並且結合病歷調閱頻率的分析，若屬高調閱頻率則其保存媒體屬性必須能夠快速調闕，低調的頻率則需要考量保存永久性問題。本文亦引用一篇個案研究，描述美國某醫院紙本病歷轉換的經驗，供大家借鏡。本文綜合考量紙本病歷轉換決策之要項，期望能有助於醫院病歷管理相關決策之用。

關鍵字

病歷電子化 ； 病歷轉換 ； 病歷保存 ； 文件生命週期

並列摘要

The coming of information management of medical records signifies the advent of a new era. However, during the process of gradually transforming the conventional ways of making medical records into the new electronic ways, it's inevitable for quite a while there will be a large volume of paper medical records left behind, still doing their jobs, and floating around in the hospital. These paper records call for huge storage space, wasteful excessive labor to deal with them, and of high attrition rate with seemingly no cure. Therefore, how to digitalize the existing traditional paper medical records in large scale becomes a vital issue.
This article focuses on an in-depth discussion of the digitalization of medical records. Such discussion can not be cut in only through the angle of cost-benefit analysis, and we must take into consideration simultaneously the estimated annual amount of medical records generated, their retention periods, and retrieve frequencies.
This article has three parts, namely an introduction to paper medical records, an estimation of the existing volume, and a case study. The introduction consists of the basic definition of medical records, active versus inactive medical records, and the way to estimate the annual amount of medical records generated, which can facilitate continuous cost estimation. As to the retention period, each country in the world varies according to its own legislation. In Taiwan, the law says that in general you should keep a medical record for at least 7 years. However, each and every hospital is allowed to make its own decision of keeping a certain type for so many years based on the requirements of teaching, education, and the health insurance system involved. Also taken into consideration is the retrieve frequency of the medical record. In case of high frequency, the emphasis will be on the nature of the medium of the record to be able to stand the fast movement; whereas in case of low frequency, the priority shifts to how to maximize its retention period. Finally, the case study depicts the experience of a certain USA hospital for the reader to refer. We hope the content of this article would be helpful for those making decisions relating to transforming paper medical records into electronic forms.

並列關鍵字

Electronic Medical Records EMR ； Medical Record Transition ； Medical Record Retention ； Document Life Cycle