中部某醫學中心電子病歷閱覽整合平台之規劃

Integrated Electronic Medical Record System of in a Medical Center in Central Taiwan

賴淑芬(Shu-Fen Lai) ； 林芷彤(Zhi-Tong Lin) ； 孫茂勝(Maw-Soan Soon)

《病歷資訊管理》 16卷1期 (2018/01) Pp. 40-51

摘要

中部某醫學中心自民國98年起配合衛生福利部電子病歷推動至今共實施148類206張電子病歷單張，並於電子病歷上線後即無紙化；在加速推動電子病歷之過程中，病歷課積極參與電子病歷的表單製作及電子病歷查閱系統之完善，包括利用表單製作系統與臨床單位溝通，將單位紙本表單e化，再與醫療資訊系統介接，協助電子病歷上線。另為使臨床人員方便查閱病人所有病歷紀錄，以提供持續性照護，與資訊部討論開發以病人為主之電子病歷閱覽整合平台（IEMR, Integrated electronic medical record），取代過去紙本病歷厚重、不易查閱之缺點，但仍保留過去醫師查閱紙本的習慣方式，並進一步提供多維度快速查閱病人院內外相關病歷紀錄之功能，提高臨床人員查閱病歷之便利性。電子病歷閱覽整合平台使得該院在推動電子病歷無紙化時，除大量降低紙張與碳粉、病歷置放空間及人力成本外，且增進醫療品質及臨床決策能力，減少降低醫療疏失發生。

關鍵字

電子病歷 ； 電子病歷閱覽整合平台

並列摘要

Since 2009, with the promotion of the electronic medical records by the Ministry of Health and Welfare, The medical center in central Taiwan has implemented a total of 206 forms of EHR in 148 categories and is paperless after the electronic medical records have been Implemented. During the accelerated promotion of electronic medical records, staff of the Medical Record Division took an active part in development of electronic medical record forms and electronic medical record review systems including the use of form generator system, communicating with clinical units, electronization of paper forms, and the system interface to the HIS (Health Information System) to facilitate the implementation of electronic medical records. In order to provide easy access to medical records to the clinicians that facilitate continuous care, the Medical Record Division worked with the Information Department to develop patient-based integrated electronic medical record (IEMR) to replace the paper medical record. The goal is to resolve the shortcomings of paper records: cumbersome to handle and difficult to read and review. While resolving these shortcomings, the team tried to retain the format that the physicians are used to with the paper medical records while include the ability for multi-dimensional quick search for the patient's medical record inside and outside of our hospital. This ability greatly improved the clinician's ability to access and review medical records. IEMR enables the hospital to promote the paperless electronic medical record, reduce a lot of paper, toner, medical record storage space and labors costs. It improved healthcare quality, clinical decision-making ability, and reduce the incidence of medical errors.

並列關鍵字

Electronic Medical Record ； Integrated Electronic Medical Record System