Jiangsu will promote the use of electronic medical records

From December 4th to 5th, Jiangsu Province, on-site exchange of experience in the development and application of electronic medical records was held at the Zhongda Hospital, Nanjing Southeast University. The reporter was informed that the health department of our province is promoting the use of electronic medical records to connect with hospitals. In the future, if a patient has a card or a doctor's appointment number when visiting a doctor, he can easily access the “one card” between hospitals.

In the Department of Respiratory Medicine at the second floor of the outpatient department of Zhongda Hospital, Zhang Yan, the attending physician, is using the computer of the outpatient doctor's workstation to access an in-patient medical record for the first half of the year in the University of China University of Medical Sciences. This is due to the full coverage of the entire hospital's electronic medical records. Doctors do not have to spend as much time in the medical record room as they used to. They took only one minute or more to view the patient's past illnesses. The patient received the most comprehensive and accurate diagnosis and treatment from the doctor in the shortest possible time.

Came to the Department of Cardiology, Zhongda Hospital ward, the reporter happened to meet Li Yongjun attending physician for a patient for discharge procedures. Looking at the discharge summary in the printed electronic medical record, Dr. Li smiled and said, "Don't underestimate this piece of paper, which records in detail the patient's hospitalization, what to pay attention to after discharge, and even the test data is written in Above, the patient is convenient after going back.” The reporter noticed that the content of this paper is clear and rich in content. It is associated with the era of past medical records in the past. There were so many contents on the discharge summary that different doctors could write. Different, some are still not clear what is the content.

The electronic medical record refers to the medical records that the medical personnel use to generate digitized information such as words, symbols, charts, figures, data, and images generated by the medical institution information system in the course of medical activities, and can realize storage, management, transmission, and reproduction of medical records. A record form of a medical record.

Professor Liu Naifeng, dean of the Zhongda Hospital affiliated with Southeast University, who is honored as “informationization president” in the industry, said that Zonda University Hospital has taken the lead in building digital hospitals in China since 2000. In 2003, the electronic medical records began to run. It took two years to realize the coverage of the entire hospital. So far, Zhongda Hospital has produced 47 shared templates, 127 specialized templates, and 140,245 electronic medical records. In 2009, it began using nursing electronic medical records to create 26 care templates. Dean Liu told reporters that the emergence of electronic medical records not only standardized the writing format, improved the quality of writing, but also standardized the procedures. The majority of patients also benefited, the patient's medical process is more secure, and service and control costs can also be improved.

In the Quality Control Office, Director Sun Yuyu said that electronic medical records can be real-time monitored in the province in the future. Through monitoring, it can promptly discover unreasonable medical measures and non-standard drug regulations. For example, Director Sun Yuyu said that in the past it was discovered that individual doctors had unreasonable problems in the joint use of antibiotics. The quality control office communicated with the related departments in a timely manner and found that the reason was that the doctor’s principle of antibiotic action was not well understood and was not timely. Please consult with other doctors in the department. Therefore, the use of antibiotics is irrational. After prompting the doctor to consult in a timely manner, unnecessary side effects are avoided.

It is understood that the development and application of electronic medical records in our province is being promoted in tandem with the new medical reform, and has been continuously improved. At present, Wuxi is already conducting a pilot project of regional electronic medical records interoperability. It is believed that in the near future, patients can hold a “citizen card” or "One Card" easily seeks medical treatment among hospitals and gradually realizes resource sharing. (Sheng Shouqin Wu Yeqing)


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