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    美國電子病歷系統發展水平報告摘要

    時間:2013-04-22 11:43:54  來源:  作者:韓立煬
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    前言:
    HIMSS是一個非盈利組織,為在醫療衛生與健康領域提供全球領先的IT技術與管理系統優化及改進方案。該組織創立于1960年,總部位于芝加哥,在美國、歐洲和亞洲都有分支機構。HIMSS發展了至少52000個會員,其中三分之二以上供職于醫療機構、政府和非盈利組織。HIMSS還包括至少225家非盈利的合作伙伴,分享醫療IT技術與管理系統的最佳實踐。HIMSS通過報道專業技術進展、最新研究成果、媒體傳播等手段,提高行業信息技術和管理系統,更好地提高醫療質量和醫療安全,減少患者費用。HIMSS輔助醫療機構進行規劃和購買決策,為醫療IT廠商和咨詢公司提供高質量的數據、分析報告和發展趨勢象限圖。
    正文:
    HIMSS組織為了評估醫院臨床系統設計了電子病歷評估模型,通過收集醫療IT的數據,檢測醫院核心技術和流程的實施深度、及支持電子化的醫療記錄狀況,從而確立該醫院的信息化水平。這種評估方法已應用于美國5300多家醫院,在加拿大、歐洲、中東和亞洲也得到廣泛使用。
    該評估模型將醫院電子病歷應用情況劃分為07級:
    0級:基本臨床業務自動化,但是實驗室、藥房、放射等關鍵部門沒有實施信息化。
    1級:實驗室、藥房、放射這三個輔助科室的系統全部安裝并實施信息化。
    2級:主要臨床輔助科室(指藥房、實驗室、放射)把醫囑和結果數據傳送到CDR(臨床數據中心),醫師可以瀏覽和檢索結果。CDR應包括可控醫學術語(CMV)和臨床決策支持引擎(CDSS),通過與CDR建立鏈接可以獲得文檔和圖像信息。
    3級:在CDR中集成臨床文檔庫(例如關鍵簽名、工作表單、護理記錄、診療圖表),至少在醫院的一個科室中實施并應用,醫師同時也可以獲得PACS的部分圖像信息。
    4級:在全院實施CPOE(計算機化醫囑錄入)系統。
    5級:在全院實施閉環用藥管理系統,包括CPOE(計算機化醫囑錄入)和電子用藥管理系統,利用自動識別技術,如RFID(射頻識別技術),支持用藥管理的“五正確”(正確的患者,正確的藥品,正確的劑量,正確的路徑和正確的服藥時間)原則,以確保患者安全。
    6級:全醫療文檔支持臨床決策,PACS影像全部取代膠片。
    7級:醫院電子病歷實現無紙化。患者信息和數據在區域范圍內共享,授權臨床醫生很方便的獲得放射影像資料。在保證患者信息安全的前提下,可以在醫院、醫生、患者、保險公司之間充分共享患者的標準化數據。
    美國電子病歷的發展趨勢如下表所示,可以看出,3級以下的醫院數量在減少,3級水平的醫院目前最多,但呈下降的趨勢,4級以上水平的醫院數量呈增長態勢。
     

    美國電子病歷應用趨勢
    階段
    關鍵能力
    2011
    2012
    7
    無紙化電子病歷,區域共享
    1.2%
    1.8%
    6
    全醫療文檔,CDSSPACS
    5.2%
    7.3%
    5
    閉環藥品管理
    8.4%
    12.0%
    4
    CPOE,臨床決策支持
    13.2%
    14.2%
    3
    臨床文檔庫
    44.9%
    41.3%
    2
    CDR,可控醫學術語
    12.4%
    11.2%
    1
    實驗室、藥房、放射系統
    5.7%
    4.8%
    0
    基本臨床業務自動化
    9.0%
    7.4%

     
     
    美國臨床醫療電子病歷產業發展簡況
    HIMSS公司還關注臨床醫療電子病歷的6個應用領域:臨床數據中心(CDR)、臨床決策支持系統(CDSS)、計算機化醫囑錄入(CPOE)、患者門戶、醫療文書、醫療門戶。這些針對臨床醫生的系統是臨床結果、患者安全的重要標志。當然,護理電子病歷應用也是重要的一部分,所有這些應用都在快速增長,特別是CDRCPOE

    臨床醫療電子病歷市場占有率
    調查樣本=4217
    2010
    2011
    2012
    臨床數據中心
    88.24%
    91.11%
    94.00%
    臨床決策支持系統
    85.72%
    88.62%
    91.25%
    計算機化的醫囑錄入
    56.58%
    67.77%
    78.35%
    患者門戶
    41.71%
    50.34%
    54.59%
    醫療文書
    53.17%
    61.80%
    68.98%
    醫生門戶
    42.87%
    50.75%
    56.27%

     
    20102012年度電子病歷領域市場顯示以下熱點:
    Ø 臨床數據中心(CDR)和臨床決策支持(CDSS):鄉村及邊遠地區醫院保持高速增長,城市醫療中心在2010年已經全部建成CDR系統。
    Ø CPOE(計算機化醫囑錄入系統):在醫學院附屬醫院市場占有率達到96%,趨于飽和,鄉村醫院正在快速建設CPOE系統。
    Ø 患者門戶:醫學院附屬醫院門戶建設在2011年到2012年期間得到快速增長。
    Ø 醫生門戶:醫學院附屬醫院醫生門戶系統在20102011年期間產生了9%的微弱增長。
    Ø 調查顯示,大型醫院更加關注與臨床醫生相關的系統建設,以便更好地為患者服務,邊遠地區的醫院則更加關注通過建設電子病歷系統獲得遠程醫療支持。
    護理電子病歷系統發展簡況
    HIMSS還關注臨床護理應用:電子用藥管理、感染監控系統、配藥系統、護士呼叫系統、護理計劃、護理文書、過敏反應。只有護理文書和電子用藥管理已得到普遍應用,其他應用還在快速增長中。

    臨床護理應用市場占有率
    調查樣本=4217
    2010
    2011
    2012
    電子用藥管理
    72.33%
    79.08%
    85.32%
    感染監控系統
    23.22%
    29.52%
    36.92%
    配藥系統
    36.80%
    50.06%
    62.94%
    護士呼叫系統
    36.87%
    46.72%
    53.95%
    護理計劃
    64.76%
    64.76%
    64.06%
    護理文書
    77.64%
    82.50%
    87.81%
    過敏反應
    29.07%
    30.71%
    33.03%

     
    上述七種應用系統的近期發展趨勢是:
    電子用藥管理:鄉村市場呈現巨大增長,超過13%
    感染監控系統:醫學院附屬醫院更加關注實施感染監控系統,主導了市場增長比例。
    配藥系統:城鄉各級醫院都呈高速增長。
    護理計劃:與2011年相比,這是唯一出現萎縮的市場。
    護理文書:鄉村醫院增長超過10%,其他類型的醫院也有不同程度的增長。
    過敏反應:鄉村醫院和急重癥醫院增長迅速。
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