SHARING PAPERLESS RECORDS AMONG PROVIDER NETWORKS

我们建议检验这样一种假设，即医疗记录 波士顿贝丝以色列医院的住院和门诊患者可以 变得完全无纸化。虽然这一目标可能不会在 建议的3年项目期，我们相信我们的成功 在没有使用计算机化在线医疗记录(OMR)的情况下 门诊环境，以及现在广泛的住院基础设施 位置预示着一个合理的成功概率。在3年内 项目期我们计划取得足够的进展以完成 令人信服。 基于计算机的病历系统已经发展了两年多 几十年。这些系统沿着两条不同的道路进化--一条 住院病人护理主要侧重于结果报告和 一种是针对非住院患者的护理，更注重组织临床 叙事和定期护理倡议。然而，这些努力已经 两人都没有关注临床医生与计算机的互动- 不是基于医疗记录，也不是基于跨 学科，跨越传统的住院和门诊界限，以及 跨越地理上分散的社区。 我们为一位在办公室工作的将军设计了一个在线病历 医疗实践。从事这项工作的医生现在经常使用这种方法 普通内科病人的护理系统。这个系统运行良好 喜欢并被大量使用。该系统鼓励临床医生输入数据 直接去吧。在开发OMR的过程中，我们包含了数据元素和程序 结构，我们发现这是必要的和充分的虚拟 在HCA，大多数供应商都不再使用纸张来绘制图表。我们 也表明这种在线医疗记录是一种有效的工具 提供临床实践指南。 我们建议将这种在线医疗记录转变为基于社区的 符合内科和外科专业兴趣的病历，以及 基于办公室和基于医院的需求。这一共享记录将促进 护理提供者之间的协作和沟通，并将作为 一种用于开发网上银行系统结构和功能模型的试验台 医疗记录。 我们将重点探索问题的结构和功能，并 药物清单是医疗记录的基本要素。这个 问题列表是我们理解在线医疗的基石 唱片。它促进了临床叙述的导航，提供 临床指南的潜在触发点，以及 用药清单，提供了有价值的患者摘要。我们将使用我们的 高使用率和高互动性的问题列表作为帮助您的试验台 经验性地得出一个问题清单词汇。我们还将重点关注 方法监控在线患者信息的保密性，并 将制定评估机密性的指标。

We propose to test the hypothesis that the medical record both for inpatient, and outpatients at Boston's Beth Israel Hospital can be rendered entirely paperless. While this goal may not be completed within the proposed 3 year project period, we believe that the success that we have had with out computerized Online Medical Record (OMR) used in an outpatient setting, and the extensive inpatients infrastructure now in place portend a reasonable probability of success. During the 3 year project period we plan to make sufficient progress to make completion compelling. Computer-based medical record systems have been in evolution for over two decades. These systems have evolved along two separate pathways - one for hospitalized patient care focused primarily on results reporting and one for non-hospitalized patient care focused more on organizing clinical narrative and periodic care initiative. However, these efforts have neither focused on the interaction of the clinician with the computer- based medical record nor on the sharing of the patient's record across disciplines, across traditional inpatient-outpatient boundaries, and across a geographically dispersed community. WE have designed an online medical record for an office-based general medical practice. Physicians in this practice now routinely use this system for the care of general medical patients. The system is well liked and heavily used. The system encourages clinicians to enter data directly. In developing OMR, we have included data elements and program structure that we have found to be necessary and sufficient to virtually eliminate the use of paper for charting by most providers at HCA. We also have shown that this online medical record is an effective vehicle for delivering clinical practice guidelines. We propose to transform this online medical record into a community-based medical record that serves medical and surgical specialty interests, and office-based and hospital-based needs. This shared record will promote collaboration and communication among care providers, and will serve as a test-bed for developing a structural and functional model of an online medical record. We will focus on exploring the structure and function of the problem and medication lists as essential elements of the medical record. The problem list is the keystone for our understanding of the online medical record. It facilitates navigation of clinical narrative, provides potential trigger points for clinical guidelines, and along with the medication list, provides a valuable patient summary. We will use our heavily used and highly interactive problem lists as a test-bed to help empirically derive a problem list vocabulary. We will also focus on methods to monitor the confidentiality of online patient information and will develop metrics to evaluate confidentiality.