The implementation of electronic signature in EMR of hospital / 中国医学装备

Objective: To gradually implement electronic signature in medical records included outpatient prescription, examination report, test report, hospitalization record and others so as to realize paperless archiving for electronic medical record(EMR) of hospital. Methods: The national law of electronic signature was used as the legal basis and the electronic signature technique was used as the technological foundation to establish electronic signature mechanism about signature, encryption and authentication. The dean who was responsible for informatization of hospital was appointed group leader, and section chief of each relevantly functional department, director of clinical department and head nurse were members of the group. Through perfect the leading group for informatization to ensure electronic signature was effectively implemented. Results: Through adhered to some principles included top-level design, gradual implementation and from easiness to difficulty, the electronic signatures about out-patient prescription, examination reports, test reports, documents of medical record and the paperless archiving for hospitalization record were realized after technique development of many years. Conclusion: The implementation of electronic signature can ensure the legality and authenticity of EMR, and the traceability of modified behavior. And it has realized paperless management for medical archives and has strengthened internal sharing of medical information in hospital.

Electronic medical record - essential for healthcare system.

In recent years, medical record-keeping has evolved into a science which is increasingly using computers and digital technology to fulfill the needs of clinicians, researchers, administrators, legal regulatory agencies and insurance companies. Medical records are important because ‘people forget and record remembers. The Medical Record Department, which is entrusted with storage, analysis and retrieval of records, plays a key role in management, planning, medical audits, policy decisions and research in any institution. Further, the information provided by this department to the health authorities of the city, state and country forms the basis on which several health-related decisions are taken at those levels. Medicolegally these records are to be preserved for, fix time periods depending on type of cases, so proper storage and damages to the conventional paper based records is emerging as a big issue to institutions. A hospital should follow well established procedures meticulously; update them regularly including the use of Information Technology for having sound Electronic Medical record Department. The transformation of conventional medical records to electronic medical records, certain Technical features and standard are to be observed strictly. In turn, this will provide more reliability, Transparency and accuracy in Medical Records. This will generate great amount of confidence in our patients, Insurance Companies, TPAs and Accreditation bodies. Electronic Medical record will be first step towards “Paperless Hospital”.

Development of Computerized Surveillance Programs based on a Hospital Electronic Medical Records System / 병원감염관리

BACKGROUND: As information technology evolves rapidly computer-based surveillance systems for nosocomial infection have been developed. Well designed computerized system could provide an opportunity for improving, enlarging, and conducting hospital-wide surveillance more efficiently in the situation with limited resources. Recently, we launched a new computerized monitoring system in a hospital where digital medical information system has been operated without paper chart. METHODS: We developed a new surveillance program based on the total Electronic Medical Record (EMR) system. Numerous critical medical information can be easily accessible through this system without further work. This includes major demographic data, essential information from the inpatient medical record, the laboratory information system, and the pharmacy information, Comprehensive Clinical Data Repository (CDR) system was also developed. CDR is potentially very useful to conduct a hospital-wide surveillance by integrating all the available information. RESULTS: This system consists of several programs in the EMR and the CDR environment. In the EMR system, inquiry for patients with fever, case ascertainment and registration of nosocomial infections, inquiry for patients with indwelling devices, microbiological reports, and data on antibiotic prescriptions were included. The CDR has integrated comprehensive inquiries for frequency of major pathogens in clinical isolates and their trends of antibiotic resistance, nosocomial infection rates based on the duration of the devices or hospitalization, and the history of antimicrobial usage based on defined daily dosage. Data obtained from the EMR and the CDR systems could be easily accessed by infectious diseases specialists and healthcare workers of infection control services at any place within the hospital. A new reporting system has been built up to facilitate identification of notifiable diseases among the list of diagnoses on the EMR. In addition, the "Alert" notice was designed to highlight isolation precautions for indicated cases. CONCLUSION: This new computerized surveillance program might be a valuable model to which other hospitals can refer to develop newer version of programs in the future.

Reflection on Application of Electronic Medical Record / 医疗卫生装备

The concept of EMR is described and the problems of EMR application are analyzed including restrictions on change permissions and writing time of EMR, and sounds in medical record management mechanism to ensure legality and effectiveness of record. Based on improvement of national policy, third-party management services institutions are estab- lished and related suggestions on technical and environmental support of EMR development are provided, and the future of its development in our country are expected.