電子化病歷品質審查系統之建置

Establishment of an Electronic Medical Record Quality Assessment System

花蓮慈濟醫院積極配合衛生署推動電子病歷，便利病人或醫院間電子病歷交換，但醫院內部同仁很難感受到電子病歷的直接好處。在現今電子病歷的世代，本院各項因應的規範、管理、逐步建置，而病歷品質確保是最重要的一環。故病歷品質審查日益重要，然而審查成本過高，造成醫院沉重負擔。本院乃規劃病歷審查電子化，期望與未來全面電子病歷的推動與接軌，並讓醫護同仁感受到電子病歷環境的優點，減少醫師審查病歷的時間與病歷組人員耗用的作業成本，同時也確保病歷書寫的品質。醫院針對現行採用的紙本病歷品質審查進行作業分析，評估病歷品質審查電子化之可行性，參考國內醫療機構現況及同儕調查結果進行比較，並對審查醫師進行使用者需求之問卷調查，再與系統開發人員及院外廠商進行相關意見訪談，彙總跨單位意見後提出電子化病歷品質審查系統架構及功能需求。經建構本院電子化病歷品質審查系統，每年門診品質審查總作業時間節省了1,136小時，節省比率達85.8%，審查醫師對此系統整體滿意度達96.7%。病歷品質審查系統電子化的實施能有效提升病歷品質審查之時效，未來醫院的住院病歷審查也將朝向全面電子化作業，期望病歷品質審查作業能夠更有品質與效率，並落實院內無紙化作業，節省人力資源與相關成本。

Tzu Chi Hospital has been actively operating in coordination with a campaign of Department of Health to promote electronic medical record (EMR) system by trying to facilitate in every possible ways the EMR exchanges between our patients and the hospital as well as among hospitals. However, it's rather difficult for our own hospital staff to sense the direct benefits of the system. In this era of EMR, this hospital has taken time and steps to build up each and every needed regulation and management detail for the system, and during which one foremost concerned and nonnegotiable item is to assure the quality of medical records. As a result of that, we've seen that EMR quality assessment becomes more and more important, and its overwhelming cost a heavy burden to the hospital. In order to cut it down, we designed a plan to computerize the assessment tasks. Our purpose is not only to link it to the future overall EMR promotion, but also to let our staff actually feel the virtue of the EMR environment, to shorten physicians' assessment process, and lower the procedure costs by our medical record personnel, beside, of course, the assurance of the quality of the records. The hospital seeks to analyze the currently still in use quality assessment process for the paper-based medical record system and evaluate the feasibility of computerizing the assessment procedures, with references of their present situations and results of similar analyses done by other Taiwanese medical facilities for comparison. Questionnaire surveys are also conducted to identify users' requests of the interface. This paper compares the survey results from doctors and users at Tzu Chi Hospital. After the survey process, interviews and feedback with program developers and companies are documented. Suggestions on EMR quality assessment from various departments are compiled to serve as a reference for future program developers. In the establishment of Tzu Chi Hospital's EMR quality assessment system, the process of the outpatient medical record assessment saves 1,136 hours a year, which equals to a saving ratio of 85.8%. The doctors' expectations of the system are also surveyed and its overall users' satisfaction reaches 96.7%. The execution of computerizing the EMR quality assessment system can effectively enhance the time effect of medical record quality assessment. The future hospital inpatient medical record assessment will also be computerized entirely in the hope that better quality and efficiency will be realized in the EMR assessment process, and also accomplished will be the complete paperless operation, plus maximum savings in human resources and costs.