Developing the electronic health record: what about patient safety?
Developing the electronic health record: what about patient safety?
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DOI：
10.1258/095148406776829103
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发表时间：
2006-05-01
影响因子：
2.1
通讯作者：
Joyce, Paul
中科院分区：
文献类型：
--
作者：
Boaden, Ruth;Joyce, Paul
本文通过对电子记录开发和实施项目（ERDIP）资助的一系列试点项目的分析，探讨了国民健康服务（NHS）中电子健康记录的发展，这是NHS信息管理局（NHSIA）工作的一个方面（截至2005年4月1日，NHSIA停止运作）。它的大部分工作是由健康连接和健康和社会护理信息中心继续进行的。分析的重点是在何种程度上确定和纠正错误的健康记录中探索通过这些项目。通过考虑记录的背景、记录的内容以及从纸质或零碎电子健康记录到综合电子健康记录的变化过程，突出了错误的内在可能性及其对患者安全的影响。虽然变化的过程突出了数据安全和访问的问题，但不同组织的起点的差异可能对患者安全构成最大的风险。通过有效利用技术，可以在一定程度上最大限度地减少与记录内容有关的问题，但需要进一步考虑编码和定性数据之间的紧张关系对患者安全的影响。本文的结论是，电子健康记录的发展必须在治理和患者安全的背景下，并阐述了影响。
This paper examines the development of electronic health records within the National Health Service (NHS) by an analysis of a series of pilot projects funded by the Electronic Record Development and Implementation Project (ERDIP), one aspect of the work of the NHS Information Authority (NHSIA) (As of 1 April 2005, the NHSIA ceased to operate. Much of its work is continued by Connecting for Health and the Health and Social Care Information Centre.) The focus of the analysis is on the extent to which identifying and correcting error within health records was explored through these projects. The inherent potential for error and resultant impact on patient safety is highlighted, by considering the context of the record, the content of the record and the process of change from paperbased or piecemeal electronic health records to integrated electronic health records. While the process of change highlights issues of data security and access, it is the variability in starting points for different organizations that possibly poses most risk to patient safety. Issues relating to the content of the record can to some extent be minimized by the effective use of technology, but the tension between coding and qualitative data requires further consideration in terms of its impact on patient safety. This paper concludes that the development of electronic health records has to be viewed within the context of governance and patient safety, and the implications articulated.