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电子病历(EMR)指医疗机构采集和保存的个人健康资料的数字化记录。EMR的实施需要在医疗机构内建立基于计算机和信息网络的个人电子健康信息储存和检索系统,实现以患者为中心的数据集成和访问。通过EMR系统与临床决策支持工具的整合,EMR可成为促进循证医疗、改善医疗质量的有力工具;通过提供完整、准确的临床数据,EMR也是医疗质量评价和持续改进的必要手段;在EMR基础上构建的、可以跨机构、跨时段、跨地域共享的电子健康记录(EHR)支持区域协同的医疗服务新模式,是提高医疗资源利用效率、改善卫生服务体系整体绩效的有效途径。EMR/EHR的实现在技术上依赖信息的标准化和信息系统的互操作性,也受法律、制度、政策、资金、观念等环境因素的制约。
EMR refers to the digital recording of personal health information collected and maintained by medical institutions. The implementation of EMR requires the establishment of computer-based and information network-based personal electronic health information storage and retrieval systems within medical institutions for patient-centric data integration and access. Through the integration of EMR systems with clinical decision support tools, EMR can be a powerful tool to promote evidence-based care and improve the quality of care. EMR is also a necessary tool for medical quality evaluation and continuous improvement by providing complete and accurate clinical data. (EHR) that supports cross-institutional, cross-time and inter-regional sharing to support regional collaborative medical services is an effective way to improve the utilization efficiency of medical resources and improve the overall performance of the health service system. The realization of EMR / EHR is technically dependent on the standardization of information and the interoperability of information systems. It is also subject to environmental factors such as laws, systems, policies, funds and concepts.