畢業(yè)設(shè)計外文文獻(xiàn)-基于計算機的患者記錄：醫(yī)療保健的基本技術(shù)

附錄A.外文翻譯-原文部分TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCareIntroductionThepatientrecordistheprincipalrepositoryforinformationconcerningapatient'shealthcare.Itaffects,insomeway,virtuallyeveryoneassociatedwithproviding,receiving,orreimbursinghealthcareservices.Despitethemanytechnologicaladvancesinhealthcareoverthepastfewdecades,thetypicalpatientrecordoftodayisremarkablysimilartothepatientrecordof50yearsago.ThisfailureofpatientrecordstoevolveisnowcreatingadditionalstresswithinthealreadyburdenedU.S.healthcaresystemastheinformationneedsofpractitioners,1patients,administrators,third-partypayers,researchers,andpolicymakersoftengounmet.AsdescribedbyEllwood(1988:1550).Theintricatemachineryofourhealthcaresystemcannolongergraspthethreadsofexperience…Toooften,payers,physicians,andhealthcareexecutivesdonotsharecommoninsightsintothelifeofthepatient…Thehealthcaresystemhasbecomeanorganismguidedbymisguidedchoices;itisunstable,confused,anddesperatelyinneedofacentralnervoussystemthatcanhelpitcopewiththecomplexitiesofmodernmedicine.Patientrecordimprovementcouldmakemajorcontributionstoimprovingthehealthcaresystemofthisnation.A1991GeneralAccountingOffice(GAO)reportonautomatedmedicalrecordsidentifiedthreemajorwaysinwhichimprovedpatientrecordscouldbenefithealthcare(GAO),Thecommitteeusesthetermpractitionerstorefertoallhealthcareprofessionalswhoprovideclinicalservicestopatients.Theseprofessionalsinclude,butarenotlimitedto,physicians,nurses,dentists,andtherapists.SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.Addanotetoyourbookmark1991).First,automatedpatientrecordscanimprovehealthcaredeliverybyprovidingmedicalpersonnelwithbetterdataaccess,fasterdataretrieval,higherqualitydata,andmoreversatilityindatadisplay.Automatedpatientrecordscanalsosupportdecisionmakingandqualityassuranceactivitiesandprovideclinicalreminderstoassistinpatientcare.Second,automatedpatientrecordscanenhanceoutcomesresearchprogramsbyelectronicallycapturingclinicalinformationforevaluation.Third,automatedpatientrecordscanincreasehospitalefficiencybyreducingcostsandimprovingstaffproductivity.Severalsourcessupporttheseconclusions.TheGAOreportedthatanautomatedmedicalrecordsystemreducedhospitalcostsby$600perpatientinaDepartmentofVeteransAffairshospitalbecauseofshorterhospitalstays(GAO,1991).Reductionsinthelengthofinpatientstayswerealsofoundinotherstudiesofcomputerizedmedicalrecordsandmedicalrecordsummaries(RogersandHaring,1979).Otherinvestigatorsfoundenhancedcareandimprovedoutcomeofcareforclinicpatients(Rogersetal.,1982)andareductioninmedicationerrors(Garrettetal.,1986).Thefirststeptowardpatientrecordimprovementisacloseexaminationoftheusersofthepatientrecord,thetechnologiesavailabletocreateandmaintainit,andthebarrierstoenhancingit.Tothatend,theInstituteofMedicine(IOM)oftheNationalAcademyofSciencesundertookastudytorecommendimprovementstopatientrecordsinresponsetoexpandingfunctionalrequirementsandtechnologicaladvances.StrengthsandWeaknessesofPaperPatientRecordsThecommittee'sliteraturereviewdidnotrevealanysubstantivedocumentationofthestrengthsofpaperpatientrecords.ThisresultmaybeHealthcareprofessionalsmightmaintainaseparatepatientrecordtoprotectsensitivedata(e.g.,psychiatrichistory)ortosupportaresearchinterest(i.e.,separaterecordscontainingdetaileddataforaresearchproject).Pharmaciescaptureinformationpertinenttopatientcarebutdonotmaintainfullpatientrecords.Informationonthemedicationsprescribedandthespecialtiesofthephysicianswritingtheprescriptionscanprovideenoughinformationtodetermineapatient'smedicalproblems,however,andpharmacyrecordsmaythusraiseconfidentialityissuessimilartothoseassociatedwithpatientrecords.Becausethecommitteefocusedmorecloselyontraditionalpatientcarerecords,thisreportdoesnotaddressissuesrelatedtopharmacyrecords.SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.×Addanotetoyourbookmarkexplainedinpartbythefactsthatthevalueofmaintainingpatientrecordsiswidelyacceptedinthehealthcarecommunityandthatpaperisthemostwidelyusedrecordkeepingform.Giventheprevalenceofpaperpatientrecords,thecommitteenotedthatsupportbypractitionersforthiskindofrecordkeepingshouldnotbeunderestimated.Timeandresourceconstraintsdidnotpermitthecommitteetosurveyuserattitudestowardpaperrecords;however,committeemembersidentifiedatleastfivestrengthsofsuchrecordsfromtheperspectiveofrecordusers:Paperrecordsarefamiliartouserswhoconsequentlydonotneedtoacquirenewskillsorbehaviorstousethem.Paperrecordsareportableandcanbecarriedtothepointofcare.Onceinhand,paperrecordsdonotexperiencedowntimeascomputersystemsdo.Paperrecordsallowflexibilityinrecordingdataandareabletorecord"soft"(i.e.,subjective)dataeasily.Paperrecordscanbebrowsedthroughandscanned(iftheyarenottoolarge).Thisfeatureallowsuserstoorganizedatainvariouswaysandtolookforpatternsortrendsthatarenotexplicitlystated.Criticismofcurrentpatientrecordsissometimessharp.Burnum(1989:484)statesthat"medicalrecords,whichhavelongbeenfaulty,containmoredistorted,deleted,andmisleadinginformationthaneverbefore."Pories(1990:47)relatesthestoryofanengineerwhowasaskedtorecommendmoreefficientuseofhealthcarepersonnelbutwhoinsteadwas"stunnedbythedisorganizationofthemedicalrecordandtheinefficienciesitimposedonthedeliveryofcare."Theengineerconcludedthat"theredesignoftherecordofferedthemostimmediateandsimpleapproachformedicalcostcontrolandforpreventionofmalpractice"(p.47).Poriesbelievesthatthissituationhasnotimprovedandthatitisnotisolated."Noonehasamonopolyontheproblem:medicalrecordsappeartobeequallybadanddangerousthroughouttheland"(Pories1990:47).Heisnotaloneinhisviewthatpatientrecordsoftenlackthefeaturesneededfortheirmostbeneficialuse.Inarecentsurveyofinternistsinacademicandprivatepractice,63percentoftherespondentsagreedwiththestatementthatpatientrecordsarebecomingincreasinglyburdensomewithoutimprovingthequalityofpatientcare(Hersheyetal.,1989).Theweaknessesofpatientrecords,asdescribedintheliteratureandintheworkofthecommittee,canbesubsumedunderfourmainheadings:(1)Althoughflexibilityinrecordingdatamaybeviewedasastrengthbytheindividualrecordingtheinformation,lackofstandardvocabularyandcodingcanposeproblemsforsubsequentusers—includingpractitioners,administrators,researchers,andthird-partypayers.SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.Addanotetoyourbookmarkcontent;(2)format;(3)access,availability,andretrieval;and(4)linkagesandintegration.ProblemswithPatientRecordContentPatientrecorddataareoftenmissing,illegible,orinaccurate(TufoandSpeidel,1971;Zuckermanetal.,1975;Bentsen,1976;Zimmerman,1978;Foxetal.,1979;RommandPutnam,1981;GerbertandHargreaves,1986;Hsiaetal.,1988;Pories,1990).Datacanbemissingforatleastthreereasons:(1)questionswereneverasked,examinationswereneverperformed,ortestswereneverordered;(2)theinformationwasrequestedandprovided,buteitheritwasnotrecordedbytheclinicianordelaysoccurredinplacingtheinformationintherecord;and(3)theinformationwasrequestedanddeliveredbutwasmisplacedorlost.Inaddition,clinicians,patients,orequipmentcanallintroduceerrorsintopatientrecords(Burnum,1989).Manystudieshaveexaminedthequalityofpatientrecordcontent.Table1-1presentsthefindingsofseveralsuchinvestigations.Themissinginformationreportedinthevariousstudiesoftenresultedinadditionalcostsofpatientcare.Forexample,anestimated11percentoflaboratorytestsinonehospitalwereorderedtoduplicatetestsforwhichfindingswereunavailabletothephysicianatthetimeofthepatientvisit(TufoandSpeidel,1971).Althoughforsomerecordsdataaremissing,inothercasescertaindataareexcessiveorredundant(Zimmerman,1978;KorpmanandLincoln,1988).Thethicknessandweightoftherecordsofpatientswithchronicproblemscanbeimposing,ifnotdaunting,andtimeconstraintsmaypreventtheuserfromfindingandusingnecessaryinformation.(Inonestudyofpaperpatientrecords,theaverageweightofaclinicrecordwas1-1/2pounds[Rogersetal.,1982].)Otherissuesrelatedtorecordcontentincludefailuretocapturetherationaleofproviders,lackofstandardizationofdefinitionsofterminology,failuretodescribethepatientexperience,lackofpatient-basedgenerichealthoutcomemeasures,andincomprehensibilityforpatientsandtheirfamilies.ProblemswithAccess,Availability,andRetrievalRecordunavailabilityanddifficultiesinaccessingrecordswhentheyareavailablearefrequentproblemsforpatientrecordusers(Pories,1990).TufoandSpeidel(1971)documentedintheirstudythatmedicalrecordswereunavailableinupto30percentofpatientvisits.Theyattributedthisrateofunavailabilitytoseveralpossiblecauses:patientsbeingseenintwoormoreclinicsonthesameday,chartsnotbeingforwarded,physicianskeepingrecordsintheirofficesorremovingthemfromtheiroffices,andrecordsbeingmisfiledinthefileroom.OnehospitalintheGAOstudyonautomatedmedicalrecordsreportedthatitcouldnotlocatemedicalrecords30percentofthetime(GAO,1991).Evenwhenrecordsarereadilyavailable,theamountoftimerequiredtoretrievenecessaryinformationfromarecordcanfrustrateusers(Fries,1974;Zimmerman,1978;Pories,1990).Forresearchers,accesstopaperrecordscanbeproblematicandisgenerallyresourceintensive(Davies,1990).Identifyingrecordsthatcontainneededdata,retrievingneededrecords,reviewingrecords,collectingdata,andenteringdataintodatasetsforanalysisaretime-consuming,expensivetasks.Yetaccesstoexistingcomputer-basedrecordscanalsoprovedifficultforresearchersbecausedocumentationonhowtousesystemsmaybelacking.Further,dataaggregationcanbehamperedbylackofcompatibilityamongsystems.BeyondTechnologyMeetingthechallengeofmanaginghealthcareinformationdependsonmorethantechnologicaladvances.Theusefulnessofanytechnologydependsonhowwellitanditsprogenyareapplied.Inadditiontotechnology,astudyoftheimprovementofpatientrecordsmustaddresshowtheuseofthoserecordsmightbeimproved,aquestionthatraisespotentiallysensitiveissues.15"Improvingrecords"and"improvingclinicalreasoning"aretopicsinevitablyconnectedtooneanotherbecauseideallytherecordreflectstheclinicalreasoningprocess.Ifbetterrecordsystemsaretobecreatedinthefuture,theusermustberecognizedaspartofthesystem,andtheproblemsolvingactivitiesofpractitionersmustbeexamined.Inadditiontotechnologicalandbehavioralopportunitiesforimprovingpatientrecords,certainstrategicissuesmustbeaddressed.Otherinformation-intensiveindustries(e.g.,banking)havesuccessfullyimplementedwidespreadcomputer-basedinformationmanagementtechnologies.Understandingthefactorsthathaveslowedthedevelopmentanddiffusionofsuchtechnologiesinhealthcareisafirststeptowardachievingmorerapidadvancesinthefuture.WhyNow?Manyattemptshavebeenmadeovertheyearstoadvanceclinicalcomputing,toreformthepatientrecord,andtoencouragehealthcareprofessionalstomaintaintherecordmoreconscientiously(e.g.,byenteringnecessaryclinicaldata).Whyshouldorhowcouldrenewedeffortstoestablishtheroutineuseofnewcomputer-basedrecordsystemssucceednowwhenpreviousattemptshavefailed?Whymightthisreporthaveasignificantimpact?Thecommitteebelievesthatfiveconditionsoftheenvironmentinwhichitsstrategicplanmightbeimplementedincreasethelikelihoodofachievingwidespreaduseofcomputer-basedpatientrecords.First,currentdemandsforpatientinformationthroughoutthehealthcaresectorwillnotdiminish;indeed,theywillprobablyincrease.Second,technologiesessentialtocomputer-basedpatientrecordsarebecomingmorepowerfulandlessexpensiveExaminationoftheroleofpatientrecordsintheclinicalprocess,asmanifestedinthedebatesurroundingtheproblem-orientedrecord,hasbeenunderwayformorethan20years(Weed,1968;Goldfinger,1972;Margolis,1979).SuggestedCitation:"1Introduction."InstituteofMedicine.1997.TheComputer-BasedPatientRecord:AnEssentialTechnologyforHealthCare,RevisedEdition.Washington,DC:TheNationalAcademiesPress.doi:10.17226/5306.×AddanotetoyourbookmarkThird,patientsandpractitionersgraduallyarebecomingaccustomedtotheuseofcomputersinvirtuallyallfacetsofeverydaylife.Fourth,anagingandmobilepopulationresultsinmoreinformationtobemanagedanddemandsforimprovedtransferabilityorportabilityofthatinformation.Finally,thecommitteebelievesthatthosecomponentsofneededreforminhealthcarethatrequireevaluation,consolidationofdata,andimprovedcommunicationwillnoteasilybeachievedwithoutreformsinthescope,use,andautomationofthepatientrecord.

附錄B.外文翻譯-譯文部分基于計算機的患者記錄：醫(yī)療保健的基本技術(shù)簡介:患者記錄是有關(guān)患者健康護(hù)理信息的主要存儲庫。它在某種程度上影響了與提供，接受或報銷醫(yī)療保健服務(wù)相關(guān)的幾乎所有人。盡管過去幾十年在醫(yī)療保健方面取得了許多技術(shù)進(jìn)步，但今天的典型患者記錄與50年前的患者記錄非常相似。由于從業(yè)人員，1名患者，管理人員，第三方付款人，研究人員和政策制定者的信息需求經(jīng)常無法滿足，因此患者記錄的這種失敗現(xiàn)在正在已經(jīng)負(fù)擔(dān)沉重的美國醫(yī)療保健系統(tǒng)中產(chǎn)生額外的壓力。如Ellwood（1988：1550）所述：我們的醫(yī)療保健系統(tǒng)錯綜復(fù)雜的機制再也無法掌握經(jīng)驗的線索，付款人，醫(yī)生和醫(yī)療保健管理人員往往不會對患者的生活有共同的見解。醫(yī)療保健系統(tǒng)已經(jīng)成為一個由錯誤的選擇;它不穩(wěn)定，困惑，迫切需要一個中樞神經(jīng)系統(tǒng)，可以幫助它應(yīng)對現(xiàn)代醫(yī)學(xué)的復(fù)雜性?；颊哂涗浀母纳瓶梢詾楦纳七@個國家的醫(yī)療保健系統(tǒng)做出重大貢獻(xiàn)。1991年美國總審計局（GAO）關(guān)于自動醫(yī)療記錄的報告確定了改善患者記錄可以使醫(yī)療保健受益的三種主要方式，委員會使用術(shù)語從業(yè)者來指代為患者提供臨床服務(wù)的所有醫(yī)療保健專業(yè)人員。這些專業(yè)人員包括但不限于醫(yī)生，護(hù)士，牙醫(yī)和治療師。首先，自動化患者記錄可以通過為醫(yī)務(wù)人員提供更好的數(shù)據(jù)訪問，更快的數(shù)據(jù)檢索，更高質(zhì)量的數(shù)據(jù)以及更多的數(shù)據(jù)顯示功能來改善醫(yī)療保健服務(wù)。自動化患者記錄還可以支持決策制定和質(zhì)量保證活動，并提供臨床提醒以協(xié)助患者護(hù)理。其次，自動化患者記錄可以通過電子捕獲臨床信息進(jìn)行評估來增強結(jié)果研究計劃。第三，自動化患者記錄可以通過降低成本和提高員工生產(chǎn)率來提高醫(yī)院效率。有幾個來源支持這些結(jié)論。GAO報告稱，由于住院時間縮短，自動醫(yī)療記錄系統(tǒng)使退伍軍人事務(wù)部醫(yī)院的每名患者的住院費用減少了600美元（GAO，1991）。在計算機化醫(yī)療記錄和醫(yī)療記錄摘要的其他研究中也發(fā)現(xiàn)了住院時間的減少（Rogers和Haring，1979）。其他研究人員發(fā)現(xiàn)，加強護(hù)理并改善臨床患者的護(hù)理結(jié)果（Rogers等，1982）和減少用藥錯誤（Garrett等，1986）。提高患者記錄的第一步是仔細(xì)檢查患者記錄的用戶，可用于創(chuàng)建和維護(hù)患者記錄的技術(shù)，以及增強患者記錄的障礙。為此，美國國家科學(xué)院醫(yī)學(xué)研究所（IOM）開展了一項研究，建議改進(jìn)患者記錄，以響應(yīng)不斷擴大的功能要求和技術(shù)進(jìn)步。紙質(zhì)病患者記錄的優(yōu)點和缺點委員會的文獻(xiàn)綜述沒有透露任何關(guān)于紙質(zhì)病歷記錄優(yōu)勢的實質(zhì)性文件。這個結(jié)果可能是醫(yī)療保健專業(yè)人員可以保留單獨的患者記錄以保護(hù)敏感數(shù)據(jù)（例如，精神病史）或支持研究興趣（即，包含研究項目的詳細(xì)數(shù)據(jù)的單獨記錄）。藥房捕獲與患者護(hù)理相關(guān)的信息，但不保留完整的患者記錄。有關(guān)所開藥物的信息和編寫處方的醫(yī)生的專業(yè)知識可以提供足夠的信息來確定患者的醫(yī)療問題，然而，藥房記錄可能因此提出類似于與患者記錄相關(guān)的機密性問題。由于委員會更密切關(guān)注傳統(tǒng)的患者護(hù)理記錄，因此本報告未涉及與藥房記錄相關(guān)的問題。部分地通過以下事實解釋了維護(hù)患者記錄的價值在醫(yī)療保健界被廣泛接受，并且該紙是最廣泛使用的記錄保存形式。鑒于紙質(zhì)病歷記錄普遍存在，委員會指出，不應(yīng)低估從業(yè)人員對這種記錄保存的支持。時間和資源限制不允許委員會調(diào)查用戶對紙質(zhì)記錄的態(tài)度;但是，委員會成員從記錄用戶的角度確定了至少五種這類記錄的優(yōu)勢：紙質(zhì)記錄對于那些因此不需要獲得新技能或行為的用戶來說是熟悉的。紙質(zhì)記錄是便攜式的，可以帶到護(hù)理點。一旦掌握，紙質(zhì)記錄就不像計算機系統(tǒng)那樣經(jīng)歷停機。紙質(zhì)記錄允許記錄數(shù)據(jù)的靈活性，并且能夠容易地記錄“軟”（即主觀）數(shù)據(jù)?？梢詾g覽和掃描紙質(zhì)記錄（如果它們不是太大）。此功能允許用戶以各種方式組織數(shù)據(jù)，并查找未明確說明的模式或趨勢。對當(dāng)前患者記錄的批評有時是尖銳的。Burnum（1989：484）指出，“長期存在錯誤的醫(yī)療記錄包含比以往更多的扭曲，刪除和誤導(dǎo)性信息?！盤ories（1990：47）講述了一位工程師的故事，該工程師被要求建議更有效地使用醫(yī)療保健人員，但卻“被醫(yī)療記錄的混亂和醫(yī)療服務(wù)的低效率所震驚”。工程師得出結(jié)論：“重新設(shè)計記錄為醫(yī)療成本控制和預(yù)防醫(yī)療事故提供了最直接，最簡單的方法”保守黨認(rèn)為，這種情況沒有改善，也沒有孤立。“沒有人對這個問題有壟斷地位：整個土地上的醫(yī)療記錄似乎同樣危險和危險”（Pories1990：47）。在他看來，患者記錄往往缺乏最有益的使用所需的功能，他并不孤單。在最近對學(xué)術(shù)和私人實踐中的內(nèi)科醫(yī)生進(jìn)行的一項調(diào)查中，63％的受訪者同意這樣的說法：患者記錄在不改善患者護(hù)理質(zhì)量的情況下變得越來越繁重（Hershey等，1989）。如文獻(xiàn)和委員會的工作所述，患者記錄的弱點可歸入四個主要標(biāo)題：（1）內(nèi)容（2）格式（3）訪問，可用性和檢索（4）聯(lián)系和整合?；颊哂涗泝?nèi)容的問題?；颊哂涗洈?shù)據(jù)經(jīng)常缺失，難以辨認(rèn)或不準(zhǔn)確（Tufo和Speidel，1971;Zuckerman等，1975;Bentsen，1976;Zimmerman，1978;Fox等，1979;Romm和Putnam，1981;Gerbert和Hargreaves，1986;Hsia等，1988;Pories，1990）。數(shù)據(jù)可能缺失至少有三個原因：（1）從未問過問題，從未進(jìn)行過考試，或者從未訂購過測試;（2）要求并提供信息，但臨床醫(yī)生沒有記錄信息，或者將信息記錄在記錄中發(fā)生了延誤;（3）信息被要求和交付但是錯放或遺失。此外，臨床醫(yī)生，患者或設(shè)備都可能在患者記錄中引入錯誤（Burnum，1989）。許多研究已經(jīng)檢查了患者記錄內(nèi)容的質(zhì)量。表1-1列出了幾項此類調(diào)查的結(jié)果。各種研究中報告的缺失信息經(jīng)常導(dǎo)致患者護(hù)理的額外費用。例如，在一家醫(yī)院中估計有11％的實驗室檢查被要求重復(fù)檢查，在患者就診時醫(yī)生無法獲得這些檢查結(jié)果（Tufo和Speidel，1971）。雖然有些記錄缺少數(shù)據(jù)，但在其他情況下，某些數(shù)據(jù)過多或過多（Zimmerman，1