SHARING PAPERLESS RECORDS AMONG PROVIDER NETWORKS

我们建议测试的假设，即医疗记录都为 波士顿贝斯以色列医院的住院病人和门诊病人可以 完全无纸化。 虽然这一目标可能无法在 在建议的3年项目期间，我们相信，我们的成功， 在没有计算机化在线医疗记录（OMR）的情况下， 门诊设置，和广泛的住院基础设施，现在在 这预示着一个合理的成功概率。 在这三年里 项目期间，我们计划取得足够的进展，使完成 引人注目。 基于计算机的医疗记录系统已经发展了两年多。 几十年 这些系统沿着两条独立的路径发展--一条是 对于住院患者护理，主要侧重于结果报告， 一个是非住院病人护理，更侧重于组织临床 叙事和定期护理倡议。 然而，这些努力 既没有关注临床医生与计算机的交互， 基于医疗记录，也不基于患者记录的共享， 学科，跨越传统的住院-门诊边界， 在地理上分散的社区中。 我们为办公室的将军设计了一个在线医疗记录 医疗实践。 目前，这一领域的医生经常使用 普通医疗病人的护理系统。 系统很好 喜欢和大量使用。 该系统鼓励临床医生输入数据 直接. 在开发OMR时，我们包括了数据元素和程序 我们发现，这种结构是必要的，也是足够的， 在HCA，大多数供应商不再使用纸张来制作图表。 我们 也表明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 服务于内科和外科专业利益的病历，以及 办公室和医院的需求。 这一共享记录将促进 护理提供者之间的合作和沟通，并将作为 一个测试平台，用于开发一个在线的结构和功能模型， 病历 我们将着重探讨问题的结构和功能， 药物清单作为医疗记录的基本要素。 的 问题列表是我们理解在线医疗的关键 记录 它有助于临床叙述的导航， 临床指南的潜在触发点，以及沿着 药物清单，提供有价值的患者摘要。 我们将用我们 大量使用和高度互动的问题列表作为测试平台，以帮助 根据经验推导出问题列表词汇表。 我们也将关注 监控在线患者信息机密性的方法， 将制定评估保密性的指标。

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.