臨床醫生對醫院信息化建設的理解

諸明 趙晶晶 張維芯

摘要：目前，信息化在整個醫療系統中占據重要地位，醫院信息化建設不僅體現了醫院的醫療現代化，也為臨床醫生及患者提供了便利，更為醫療衛生事業提供了大量的統計、研究數據，促進衛生事業的進一步發展。作為一名臨床醫生，在參與信息化建設中發現，除了達到信息化本身的專業構架要求，臨床一線以及患者的切身體驗及需求對信息化建設的優化具有重要指導意義，發揮臨床醫生及患者的主觀能動性解決一些細節問題對整個信息化建設具有促進作用。醫療事業最終服務的是大眾，當今的醫患關系緊張以及醫患糾紛事件的不斷增加，與醫患之間溝通不充分、就醫體驗不佳有一定的關系，提高醫務工作效率改善患者就醫體驗也是考驗信息化建設是否成功的要點。總之，信息系統的適用主體是臨床醫生，但最終是要服務于患者群體。

關鍵詞：醫院信息化建設;臨床需求;就醫體驗;醫患關系

中圖分類號：R391? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?文獻標識碼：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

隨著醫院信息化建設的不斷深入，圍繞臨床效率與醫療質量提升、學科建設與科研支持、醫院精細化管理等方面的需求，加大信息化投入，增強信息化應用的產出，信息化建設已成為強院、立院之根本。眾所周知，醫院信息化建設經歷三個階段：①以財物管理為核心，實現醫院管理信息化;②以電子病歷為核心，實現臨床管理信息化;③以信息交換為核心，實現區域衛生服務信息化。近年來，各類醫院醫療應用系統大量涌現，其熱點已由以費用管理核算為核心向著以電子病歷為核心的現代化醫院信息系統建設轉變。為能更好、更準確地服務患者，需借助醫療信息化手段、病歷的有效管理與查閱以及區域性數據共享來實現，其中，最先受益的是臨床醫生，最終服務于患者[1-3]。