What Is an Electronic Patient Record?

Electronic medical records (EMR, Electronic Medical Record) are also called computerized medical record systems or computer-based patient records (CPR).

Electronic medical record

Electronic medical records (EMR, Electronic Medical Record) are also called computerized medical record systems or computer-based patient records (CPR).

It is a digital medical record that is stored, managed, transmitted, and reproduced with electronic devices (computers, health cards, etc.) to replace handwritten paper medical records. Its contents include all the information of the paper medical records. The National Institutes of Medicine will define EMR as an electronic patient record based on a specific system that provides users with the ability to access complete and accurate data, alerts, prompts, and clinical decision support systems.

Chinese name

Electronic record

Foreign name

EMR, Electronic Medical Record

Issuing authority

Ministry of Health

Function

Medical

The medical record is the original record of the whole process of the diagnosis and treatment of the patient in the hospital. It contains the homepage, the course record, the results of the examination, the doctor's order, the operation record, the nursing record and so on. Electronic medical records (EMR) refer not only to static medical record information, but also to related services provided. It is electronically-managed information about an individual's lifetime health status and health care behavior, and all process information related to the collection, storage, transmission, processing, and utilization of patient information. The National Institutes of Medicine will define EMR as an electronic patient record based on a specific system that provides users with the ability to access complete and accurate data, alerts, prompts, and clinical decision support systems.

Electronic medical records are generated with the application of hospital computer management network, information storage media such as compact discs and IC cards, and the globalization of the Internet. Electronic medical records are an inevitable product of information technology and network technology in the medical field, and an inevitable trend of the modern management of hospital medical records. The preliminary application in clinical practice has greatly improved the hospital's work efficiency and medical quality, but this is only electronic medical records. The start of the application.

Electronic medical records (EMR, Electronic Medical Record) are also called computerized medical record systems or computer-based patient records (CPR). It replaces hand-written paper medical records with electronic devices (computers, health cards, etc.) to save, manage, transmit, and reproduce digitized patient medical records. Its contents include all the information of the paper medical records.

Electronic Medical Record (EMR) is defined in the Electronic Medical Record Basic Structure and Data Standard Electronic Medical Record issued by the Ministry of Health as: Electronic medical record is the clinical diagnosis and guidance of medical institutions for outpatients, inpatients (or health objects) Intervening, digital health service work records.

Electronic medical records are digital patient medical records that are stored, managed, transmitted, and reproduced by electronic devices (computers, health cards, etc.), instead of handwritten paper medical records. The electronic medical record has the characteristics of initiative, completeness and correctness, knowledge connection, and timely acquisition. It is a digital medical service record of medical institutions for clinical diagnosis and guidance and intervention of outpatients, inpatients (or health care objects).

For more than 20 years, some major hospitals in Europe and the United States have begun to establish

Relationship with HIS

With the success of China s medical reform pilots, the successful experience of medical reform is being continuously spread to other regions. During the medical reform process, medical clinics and hospitals implement office automation and electronic medical records, which is very important for medical data conversion of electronic medical records. The problem. All conversion processes are not static because medical clinics may require two distinct conversions. There are usually two methods for the conversion of old data that we see, batch scan conversion and manual input conversion.

Batch scan conversion is to scan paper medical records into image files to retain the original medical records. These scans will be retained in the electronic medical record, but personal search data fields will not be provided in the future. There are many benefits to converting from paper medical records to image data, and there is no need to consider integrating new databases with mismatched medical record information. Old information may be locked while entering or different standards and relationships need to be set manually, making it difficult for this information to match electronic data correctly. Image-based files have the following disadvantages: After the original data is saved as a PDF file, personal data cannot be electronicized and cannot be included in the clinic's statistics. It is even more difficult or impossible to query these files and obtain information reports. If you want to know if a patient received a certain vaccine five years ago, you may still need to look up these PDF files manually instead of looking for "pre-classification."

Manual input conversion is to input the previous paper medical records manually into the new online data.

1. The electronic medical record management system is not a specific business system. It should be defined as a management platform, which is mainly responsible for the management, matching, merging, archiving, borrowing, and exchange of medical record information (text, image, image, sound, etc.). It is mainly for the management of medical record data sets, which is somewhat like a health file;

2. Electronic medical records are not as simple as writing medical records. Medical records are the result records of various medical activities. It does not mean that when I develop a text writer, it is an electronic medical record. The medical record room of electronic medical records comes from the results of many clinical systems. Numerous systems used by medical staff in their daily work, including various doctor stations, nurse stations, laboratory systems, radiology systems, anesthesia systems, ECG monitoring systems, operating room systems, intensive care systems, consultation systems, etc. When these systems are running, they will generate various processes such as application, approval, processing, and feedback to manage the informationization of the entire clinical work. The medical documents that meet the medical record specifications will eventually be produced, and they are legally meaningful documents. Both will be part of the electronic medical record;

3 When the electronic medical record is used clinically, if it is in the hospital, it is necessary to archive various information into the medical record and display it uniformly for use by doctors during rounds. This is like a medical record folder during rounds. Once the patient is discharged, once the file is archived, the viewing of this information requires application, approval, and return, as well as the recording of browsing information and resolution information;

4 External interaction of electronic medical records: For example, with the health file platform or regional electronic medical record platform, there will be a problem of exchanging standards. This standard organization needs an electronic medical record management system to complete.

Overview

The medical information system with electronic medical records as the core is to construct an information model structure that is resource-sharing, safe, efficient, and easy to use. The system usually adopts a three-tier architecture. The bottom layer is an electronic medical record database server for storing and managing data such as medical records. The middle layer is an application server and a web server. The application server is used to implement the system's business logic (such as medical record management, medical record archiving). , Medical record query, statistical reports, etc.), complete various complex management operations and data access. The web server is used to provide system web services (such as medical record query, information announcement, email, online registration, etc.), and can also be managed through the network management Perform data exchange and information transfer with external systems; the top layer is the client, such as medical workstations and inquiry workstations located in the outpatient hall, registration department, inpatient department, etc. Windows users complete related operations through special programs.

The electronic medical record system is a key application of the hospital. It is related to important data of the medical record and patient privacy. Once hidden dangers occur, irreparable losses will occur. Therefore, the construction of an IT system for electronic medical records must consider safety, stability, and reliability. The electronic medical record system is designed with a structured and modular structure. Most of them adopt a dual-machine hot backup solution, and use password control, file storage and transmission encryption to ensure data security.

Performance points

The electronic medical record system is a database application, including online archives of tens of thousands or even 100,000 levels of electronic medical records; multi-user online data search and call, like the medical records of similar diseases, to help doctors choose the best medical solution; intelligent knowledge base to assist doctors Establish a medical plan; warn of medical violations, such as contraindications to drug interaction compatibility, to avoid medical errors; online professional databases, such as drug databases, for doctors to query.

Take a large third-class hospital as an example, the average outpatient volume is as high as 7000-10,000 person-times / day. In this way, the annual outpatient volume is as high as 2.4 million-2.5 million person-times / year. The electronic medical record system stores a large amount of medical record data. When patients At the time of the doctor's appointment, the doctor quickly and accurately found the patient's data from more than 2 million copies of data through an electronic medical record system. It can be seen from the above application that building a simplified and efficient electronic medical record information system requires a powerful computing platform. The server has powerful computing performance and provides more than 20 RAS technologies. The system reliability is 99.999%, which can effectively meet the needs of the hospital electronic medical record system computing platform.

Security Mechanism

The electronic medical record is a record of the patient's medical process that has been performed, and is also the basis of the medical operation to be performed; the content of the medical record is legally effective regardless of the patient's medical information or the patient's personal privacy. Therefore, the use of electronic medical record systems must establish a set of security mechanisms. This mechanism should cover the various components of different representations of patient information, and should be controlled to specific patients. It needs to authorize the users of information, who can modify which information, and who can read which information; meanwhile, some important operations should be tracked and recorded.

In the construction of information systems, there are corresponding solutions on access layer security, network layer security, and data layer security, but the system layer is often ignored. According to the relevant national standards, the security server starts from the characteristics of the server security itself, from the motherboard, security dedicated chips and other low-level hardware to the operating system and upper-layer application software. It integrates to build a software-hardware integrated security server product that meets the requirements of the standard three levels. The server organically integrates multiple information security technologies such as server operating status monitoring, network status monitoring, mandatory access control, security management, and security auditing. It provides server users with a full range of security from three aspects: device security, operational security, and data security. Function, solve the increasingly severe security threats faced by hospital users.

Storage backup scheme

The patient's electronic medical record information needs to be kept for a long time. However, the electronic medical record information has a large amount of data, and it is impossible to keep all patient information online for a long time. As an electronic medical record system, not only the long-term preservation of patient information must be achieved, but also the patient's information cannot be lost in the event of a failure, and can also be extracted when needed. To this end, it is necessary to establish a hierarchical storage structure to realize the unification of mass storage and real-time access; to automatically back up the medical records of expired patients; to provide online recovery tools for medical records that need to be extracted; to recover data after a failure To the breakpoint state.

Supplier Status

Since the latest specifications recommended by the Ministry of Health, in order to respond to market changes and rapid needs, most manufacturers generally purchase electronic medical record controls and develop them. A small number of companies can invest a large amount of research and development efforts in time to update the core controls in time to meet the latest national regulations. . At the same time, the brand with core controls and a full set of electronic medical record systems has electronic medical records, which is a research and development by a technology company focusing on electronic medical record systems. The system is completely structured, and the imitation WORD style is very characteristic. There are a large number of free downloads available on the Internet, allowing customers to purchase with no risk.

Yixun electronic medical record system conforms to relevant national plans, collects, summarizes, stores, processes, and displays all clinical diagnosis and treatment data, and seamlessly connects with various medical and health business systems to realize the sharing and exchange of electronic medical records in the region.

In his annual State of the Union address to the House of Representatives, US President Bush summarized the goal of establishing electronic medical records into three sentences: "Computerized health records, we can avoid serious medical accidents, reduce the increase in medical costs, and improve medical standards."

Electronic Medical Record Basic Specifications

(Trial)

Chapter I General Provisions

The first is to standardize the management of electronic medical records in medical institutions and guarantee the legitimate rights and interests of both doctors and patients. Develop this specification.

Article 2 This specification applies to the establishment, use, preservation and management of electronic medical records in medical institutions.

Article 3 Electronic medical records refer to medical personnel using medical information, such as text, symbols, charts, graphics, data, images, and other digital information generated by the information system of medical institutions during medical activities, and can realize the storage, management, transmission and reproduction of medical information Record is a form of recording of medical records.

Medical record files edited and printed using word processing software are not part of the electronic medical records referred to in this specification.

Article 4 The construction of the electronic medical record system of medical institutions shall meet the needs of clinical work, follow the medical work process, and ensure medical quality and medical safety.

Chapter II Basic Requirements for Electronic Medical Records

Article 5 The entry of electronic medical records shall follow the principles of objectivity, truth, accuracy, timeliness and completeness.

Article 6 The entry of electronic medical records shall be in Chinese and medical terms, which shall be accurate, the sentences shall be smooth, and the punctuation shall be correct. Common abbreviations in foreign languages and symptoms, signs, and disease names without official Chinese translations can be used in foreign languages. The date of recording shall be in Arabic numerals, and the time of recording shall be in 24-hour format.

Article 7 Electronic medical records include outpatient (emergency) electronic medical records, inpatient electronic medical records, and other electronic medical records. The contents of the electronic medical records shall be implemented in accordance with the "Basic Specifications for Writing Medical Records" of the Ministry of Health, and the names, formats and contents of the items uniformly formulated by the Ministry of Health shall not be used without permission.

Article 8 The electronic medical record system shall provide operators with proprietary identification and identification means, and shall be provided with corresponding authority; the operator shall be responsible for the use of his own identification.

Article 9 After the medical personnel use the identity to log in the electronic medical record system to complete various records and other operations and confirm them, the system should display the medical personnel's electronic signature.

Article 10 The electronic medical record system shall set the authority and time limit for medical personnel to review and modify. The medical records recorded by the intern medical staff and the medical staff during the probation period shall be reviewed, revised and confirmed by electronic signatures of medical staff legally practicing in this medical institution. When medical personnel make changes, the electronic medical record system should identify, save traces of previous changes, mark the correct time of modification, and the information of the person who modified it.

Article 11 The electronic medical record system shall establish a database of personal information for patients (including name, gender, date of birth, ethnicity, marital status, occupation, work unit, residential address, valid ID number, social security number or medical insurance number, contact phone Etc.), grant unique identification numbers and ensure that they correspond to the patient's medical records.

Article 12 The electronic medical record system shall have strict copy management functions. The same information of the same patient can be copied. The copied content must be proofread. The information of different patients must not be copied.

Article 13 The electronic medical record system shall meet the national information security level protection system and standards. It is strictly forbidden to tamper with, falsify, conceal, snatch, steal or destroy electronic medical records.

Article 14 The electronic medical record system shall provide technical support for the quality control of medical records, medical and health service information, statistical analysis of data, and review of medical insurance expenses, including classification and inquiry of medical expenses, surgical grading management, clinical path management, single disease quality control, Statistics of medical quality management and control indicators such as the average hospitalization day, the average hospitalization day before surgery, bed utilization rate, reasonable medication monitoring, and the ratio of drugs to total income. Use system advantages to establish a medical quality assessment system, improve work efficiency and ensure medical quality Standardize diagnosis and treatment behaviors and improve hospital management.

Chapter III Basic Conditions for Implementing Electronic Medical Records

Article 15 The establishment of an electronic medical record system by a medical institution shall meet the following requirements:

(1) Special management department and personnel are responsible for the construction, operation and maintenance of the electronic medical record system.

(2) Information technology, equipment and facilities for the operation and maintenance of the electronic medical record system to ensure the safe and stable operation of the electronic medical record system.

(3) Establish and improve the relevant systems and procedures for the use of electronic medical records, including management procedures for personnel operation, system maintenance and change, and emergency plans in the event of system failure.

Article 16 The operation of the electronic medical record system of medical institutions shall meet the following requirements:

(1) It has the systems and measures to ensure the safety of electronic medical record data, has a data backup mechanism, and qualified medical institutions should establish an information system disaster recovery system. It should be able to implement emergency plans in the event of system failure to ensure the continuity of the electronic medical record business.

(2) Implement hierarchical management of operator's authority to protect patients' privacy.

(3) It has the ability to trace back the operations of electronic medical record creation, editing and filing.

(4) The terms, codes, templates and standard data used in electronic medical records shall meet the requirements of relevant regulations.

Chapter IV Management of Electronic Medical Records

Article 17 Medical institutions shall establish an electronic medical record management department and be staffed with full-time personnel, and shall be specifically responsible for the management, collection, preservation, retrieval, and copying of electronic medical records for outpatient (emergency) and inpatient electronic medical records of the institution.

Article 18 The electronic medical record system of a medical institution shall ensure that medical personnel need to consult the medical records, and be able to provide and complete the electronic medical record data of the patient in a timely manner.

Article 19 Non-text data (CT, magnetic resonance, ultrasound and other medical image information, electrocardiogram, audio recording, video, etc.) generated during the patient's diagnosis and treatment activities shall be incorporated into the management of the electronic medical record system, and shall be accessed at any time and be complete.

Article 20 The records of outpatient (emergency) medical records in the electronic medical records of outpatient clinics shall be archived upon confirmation by the attending physician, and shall not be modified after filing.

Article 21 The electronic medical records of inpatients are filed with the patients after they are discharged, and are archived by the superior doctor after the patient's discharge is reviewed and confirmed. After the filing, the electronic medical records management department uniformly manages them.

Article 22 For medical information materials such as bar codes and informed consent forms of implant materials that cannot be electronicized, measures can be taken to digitize the information and incorporate it into the electronic medical record and retain the original.

Article 23 The archived electronic medical records shall be stored in electronic data mode. If necessary, paper versions may be printed. The printed electronic medical records shall have uniform specifications, fonts, formats, etc.

Article 24 The electronic medical record data shall be saved and backed up, and the backup data shall be regularly tested for recovery to ensure that the electronic medical record data can be restored in a timely manner. When the electronic medical record system is updated or upgraded, the inheritance and use of the original data should be ensured.

Article 25 Medical institutions shall establish a system for the security and confidentiality of electronic medical record information, set the corresponding authority for medical personnel and relevant hospital management personnel to read, copy, and print electronic medical records, establish an electronic medical record use log, and record the personnel, operating time, and content. Without authorization, no unit or individual may read or copy electronic medical records without authorization.

Article 26 Medical institutions shall accept applications for the following persons or institutions to copy or reproduce electronic medical records:

(1) the patient himself or his agent;

(2) Close relatives of the deceased or their agents;

(3) Basic medical security management and handling organizations that pay for patients;

(4) The insurance institution authorized by the patient.

Article 27 Medical institutions shall designate specialized institutions and personnel to be responsible for accepting applications for copying or duplicating electronic medical record materials, and retain copies of the applicant's valid identity certificate, their legal certification materials, and insurance contracts. When accepting an application, the applicant shall be required to provide materials in accordance with the following requirements:

(1) If the applicant is the patient himself, he shall provide his valid identity certificate;

(2) If the applicant is a patient agent, the valid identity certificate of the patient and his agent, and legal certification materials of the applicant's agent relationship with the patient shall be provided;

(3) If the applicant is a close relative of the deceased patient, the death certificate of the patient and the valid identity certificate of the close relative, and legal certification materials that the applicant is a close relative of the deceased patient shall be provided;

(4) If the applicant is a close relative of the deceased patient, the death certificate of the patient, valid identity certificate of the close relative of the deceased patient and his agent, legal certification materials of the relationship between the deceased patient and his close relative, and the close relative of the applicant Statutory certification of agency relationship;

(5) if the applicant is a basic medical security management and handling agency, it shall be implemented in accordance with the relevant provisions of the corresponding basic medical security system;

(6) If the applicant is an insurance institution, it shall provide a copy of the insurance contract, the valid identity certificate of the undertaking personnel, and the legal certification materials agreed by the patient himself or his agent; Proof of identity, statutory proof materials agreed by the close relatives of the deceased or their agents. Except as otherwise stipulated in the contract or law.

Article 28 If the public security and judicial organs need to collect and retrieve electronic medical records due to the handling of cases (events), medical institutions shall truthfully provide after the public security and judicial organs have issued statutory certificates and executed valid identity certificates of public officials.

Article 29 The scope for medical institutions to copy or copy electronic medical records for applicants shall be in accordance with the Ministry of Medical Institutions' Medical Record Management Regulations.

Article 30 After accepting an application for copying or duplicating electronic medical record materials, a medical institution shall provide the medical records after the medical staff has completed the medical records within the prescribed time limit.

Article 31 After the photocopy or reproduction of the medical record data is verified by the applicant, the medical institution shall affix a proof stamp on the paper version of the electronic medical record or provide an electronic version of the medical record that has been locked and cannot be changed.

Article 32 When a medical accident dispute occurs, the electronic medical records shall be locked in the presence of both the doctor and the patient and an identical paper version shall be produced for sealing. The sealed paper medical records shall be kept by the medical institution.

Chapter V Supplementary Provisions

Article 33 Provincial health administrative departments may formulate relevant implementation rules in their jurisdictions in accordance with this specification.

Article 34 The basic specifications of TCM electronic medical records shall be separately formulated by the State Administration of Traditional Chinese Medicine.

Article 35 The interpretation of this code is the responsibility of the Ministry of Health.

Article 36 This Code shall come into effect on April 1, 2010.