除了COVID-19:切換電子病曆時的數據考慮

This is the first article in a series on topics inspired by a focus group discussion among members of CHIME (College of Healthcare Information Management Executives) about strategies used to adapt during the pandemic.

As the backbone of a hospital, the electronic medical record (EMR) contains critical patient data such as scheduling, registration, medications, diagnoses, treatment plans, and billing. Hospital and health system leaders shared challenges associated with switching their EMR. Replacing an existing EMR system can be costly and disruptive, presenting a range of operational and clinical considerations, including how to handle data.

While planning for the new software system, a move also provides the opportunity to evaluate the organization’s document management system (DMS). Consolidating can reduce the organizational and provider time necessary for document retrieval, while managing legacy documents and preserving the legal medical record. Migrating historical records to a DMS can help save the healthcare system money and allow the documents and data to be brought back to life as usable and accessible in the new systems.

Restructure workflows

Another document management area to consider is restructuring workflows and naming methods. Large health organizations need to maintain large quantities of patient, billing, legal, and other content, often decades old. This content is typically saved in various file types and systems, which can impede information flow and pose a security risk when not managed properly.

作者:Jennifer Marshall，醫療保健技術分析解決方案技術產品管理總監

這是一本的第一篇文章係列討論由CHIME會員小組討論所啟發的主題(醫療保健信息管理高管學院)關於大流行期間的適應策略。

作為醫院的骨幹，電子病曆(EMR)包含重要的患者數據，如日程安排、注冊、藥物治療、診斷、治療計劃和賬單。醫院和衛生係統的領導分享了與轉換EMR相關的挑戰。更換現有的EMR係統可能成本高昂且具有破壞性，這涉及到一係列操作和臨床方麵的考慮，包括如何處理數據。

在規劃新的軟件係統時，移動也提供了機會評估組織的文件管理係統(DMS)。在管理遺留文檔和保存合法醫療記錄的同時，合並可以減少組織和提供程序進行文檔檢索所需的時間。將曆史記錄遷移到DMS可以幫助醫療保健係統節省資金，並允許將文檔和數據恢複到新係統中可用和可訪問的狀態。

重組工作流程

另一個需要考慮的文檔管理領域是重構工作流和命名方法。大型衛生組織需要維護大量的患者、賬單、法律和其他內容，通常有幾十年的曆史。這些內容通常保存在各種文件類型和係統中，如果管理不當，可能會阻礙信息流並造成安全風險。

Healthcare organizations must remain legally compliant with document retention policies that govern patient records. State and federal laws, medical board and association policies, and the type of record (for example, an adult patient versus a pediatric patient) can impact how long to keep a medical record.

Effective document management can drive workforce efficiency, improve workflow for your hospital or health system, and streamline document retention. Watch for the next topic in this series, which will discuss security.

自動化文檔保留策略

醫療保健組織必須在法律上遵守管理患者記錄的文檔保留策略。州和聯邦法律、醫療委員會和協會政策以及記錄類型(例如，成人患者與兒童患者的比較)都可能影響醫療記錄的保存時間。

有效的文檔管理可以提高工作人員的效率，改善醫院或衛生係統的工作流程，並簡化文檔保存。關注本係列的下一個主題，它將討論安全性。