臨床醫(yī)生對醫(yī)院信息化建設(shè)的理解

諸明 趙晶晶 張維芯

摘要：目前，信息化在整個醫(yī)療系統(tǒng)中占據(jù)重要地位，醫(yī)院信息化建設(shè)不僅體現(xiàn)了醫(yī)院的醫(yī)療現(xiàn)代化，也為臨床醫(yī)生及患者提供了便利，更為醫(yī)療衛(wèi)生事業(yè)提供了大量的統(tǒng)計、研究數(shù)據(jù)，促進(jìn)衛(wèi)生事業(yè)的進(jìn)一步發(fā)展。作為一名臨床醫(yī)生，在參與信息化建設(shè)中發(fā)現(xiàn)，除了達(dá)到信息化本身的專業(yè)構(gòu)架要求，臨床一線以及患者的切身體驗及需求對信息化建設(shè)的優(yōu)化具有重要指導(dǎo)意義，發(fā)揮臨床醫(yī)生及患者的主觀能動性解決一些細(xì)節(jié)問題對整個信息化建設(shè)具有促進(jìn)作用。醫(yī)療事業(yè)最終服務(wù)的是大眾，當(dāng)今的醫(yī)患關(guān)系緊張以及醫(yī)患糾紛事件的不斷增加，與醫(yī)患之間溝通不充分、就醫(yī)體驗不佳有一定的關(guān)系，提高醫(yī)務(wù)工作效率改善患者就醫(yī)體驗也是考驗信息化建設(shè)是否成功的要點。總之，信息系統(tǒng)的適用主體是臨床醫(yī)生，但最終是要服務(wù)于患者群體。

關(guān)鍵詞：醫(yī)院信息化建設(shè);臨床需求;就醫(yī)體驗;醫(yī)患關(guān)系

中圖分類號：R391? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?文獻(xiàn)標(biāo)識碼：B? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? DOI：10.3969/j.issn.1006-1959.2019.04.009

文章編號：1006-1959（2019）04-0024-04

Abstract：At present， informatization plays an important role in the entire medical system. Hospital information construction not only reflects the hospital's medical modernization， but also provides convenience for clinicians and patients. It also provides a large amount of statistics and research data for medical and health undertakings. Further development of the health industry. As a clinician， in the information construction， it is found that in addition to meeting the professional framework requirements of informationization， the clinical frontline and the patient's personal experience and needs have important guiding significance for the optimization of information construction， and play the role of clinicians and patients. Subjective initiative to solve some details of the problem has contributed to the entire information construction. The medical service ultimately serves the public. Today's doctor-patient relationship is tense and the number of doctor-patient disputes is increasing. There is a certain relationship between inadequate communication between doctors and patients and poor medical experience. Improving the efficiency of medical work and improving patients' medical experience is also Test the key points of the success of informatization construction. In short， the applicable body of the information system is the clinician， but ultimately it is to serve the patient population.

Key words：Hospital information construction;Clinical needs;Medical experience;Doctor-patient relationship

隨著醫(yī)院信息化建設(shè)的不斷深入，圍繞臨床效率與醫(yī)療質(zhì)量提升、學(xué)科建設(shè)與科研支持、醫(yī)院精細(xì)化管理等方面的需求，加大信息化投入，增強(qiáng)信息化應(yīng)用的產(chǎn)出，信息化建設(shè)已成為強(qiáng)院、立院之根本。眾所周知，醫(yī)院信息化建設(shè)經(jīng)歷三個階段：①以財物管理為核心，實現(xiàn)醫(yī)院管理信息化;②以電子病歷為核心，實現(xiàn)臨床管理信息化;③以信息交換為核心，實現(xiàn)區(qū)域衛(wèi)生服務(wù)信息化。近年來，各類醫(yī)院醫(yī)療應(yīng)用系統(tǒng)大量涌現(xiàn)，其熱點已由以費(fèi)用管理核算為核心向著以電子病歷為核心的現(xiàn)代化醫(yī)院信息系統(tǒng)建設(shè)轉(zhuǎn)變。為能更好、更準(zhǔn)確地服務(wù)患者，需借助醫(yī)療信息化手段、病歷的有效管理與查閱以及區(qū)域性數(shù)據(jù)共享來實現(xiàn)，其中，最先受益的是臨床醫(yī)生，最終服務(wù)于患者[1-3]。