建置電子病歷管理系統- 以某區域教學醫院為例

Implementating An Electronic Medical Record Management System -A Case Study of a Regional Teaching Hospital

陳怡敏(YI-MIN CHEN)

指導教授 ： 張怡秋

國立中正大學/管理學院/資訊管理系醫療資訊管理研究所/碩士(2016年)

摘要

衛生福利部統計自1999年電子病歷(Electronic Medical Record；EMR)元年起至2015年為止，宣告實施電子病歷醫院已達80.4%、其中可提供院際電子病歷互通者佔81.9%，此電子病歷推動成效意味著在國家政策持續推動下應可達電子健康紀錄(Electronic Health Record；EHR)終極目標。電子病歷發展的核心價值在於提升醫療照護品質與病人安全、減少醫療疏失發生、促進院際病歷互通整合、減少病人重複檢驗檢查及用藥，在醫療法及醫院評鑑雙重規定下，醫院必須建置一套電子病歷管理系統，以資訊系統管理醫療業務中產生的電子病歷文件，藉此管控及提升電子病歷管理品質，達到電子病歷核心價值，讓國家電子病歷資訊透明化，資訊共享。
本研究以個案研究法探討以病歷管理單位角度建置之電子病歷管理系統其應具備之功能，系統建置後以質性深度訪談8位病歷管理人員評估系統六大構面效益。研究結果發現在混合病歷管理下，(1)個人經驗如業務屬性、年資、經驗會影響系統使用及個人成長，(2)系統架構的複雜度跟教學者之個人經驗明顯影響教學成效，(3)應依病歷管理人員使用需求建置一套穩定又可提供完整、正確、整合資訊的電子病歷管理系統，(4)電子病歷管理系統可提升病歷管理工作效率及病歷管理專業度。
隨著電子病歷發展白熱化以及國家政策推動下，醫院必須建置電子病歷管理系統，本研究除提供正在規劃與開發電子病歷管理系統之醫療院所參考外，建置過程亦建議應考量使用者需求，建置以病患為中心之電子病歷管理系統，讓醫院病歷管理人員透過此醫療資訊平台管理電子病歷，確保電子病歷管理品質，達到國家互通要求，取代紙本病歷之管理。

關鍵字

電子病歷 ； 電子健康紀錄 ； 電子病歷管理系統

並列摘要

Statistics from the Ministry of Health and Welfare in 1999 EMR year until 2015, declared the implementation of Electronic Medical Record hospital has reached 80.4%, which provides inter-hospital Electronic Medical Record exchange accounted for 81.9%, this means that Electronic Medical Records to promote the effectiveness of national policies should continue to push up under the Electronic Health Record (EHR) ultimate goal. Core Value EMR development is to raise the quality of health care and patient safety, reduce medical errors occur, promote the integration of intercollegiate record sharing, reduce duplication of testing patient examination and treatment, in medical law and hospital accreditation under the provisions of double, hospitals must build an Electronic Medical Record Management System, use Information Systems to management the Electronic Medical Record file produced from medical business, whereby control and enhance the quality of management of Electronic Medical Records, achieve EMR core values, let the national Electronic Medical Record transparency, information sharing.
This study used a case study method to investigate should have the capabilities to build the medical record management unit angle of Electronic Medical Records Management System, after the system to build through depth qualitative interviews with 8 records management personnel to evaluation system of six facets benefit. The results found that under the hybrid records management(1) personal experience such as business property, seniority, experience will affect the system and personal growth, (2)complexity of the system architecture and the personal experience of the instructor's significantly influence the effectiveness of teaching, (3)according to records management personnel demand for the use to build a stabilization but also to provide a complete, accurate, integrated information of Electronic Medical Record Management System,(4)Electronic Medical Record Management System can improve the efficiency of medical record management and records management professional degree.
With an Electronic Medical Record development of the white-hot and national policies to promote, hospitals must build Electronic Medical Record Management System, in addition to this study we are in the planning and development of Electronic Medical Record Management System of medical institutions reference, build process also recommended that users' needs should be considered, build patient-centered of Electronic Medical Record Management System, let hospital records management personnel can management Electronic Medical Record through this medical information platform to ensure the quality of management of Electronic Medical Record achieve national requirements for exchange, replace the management of paper records.

並列關鍵字

Electronic Medical Record(EMR) ； Electronic Health Record(EHR) ； Electronic Medical Record Management System

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