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以现代化病案管理模式为基础,阐述电子病历实施过程中遇到的一些问题,如信息标准不统一而阻碍电子病历的推广、法律地位及法律性质不确定导致在诉讼中不能作为直接证据、给患者隐私权带来威胁等。以电子病历的稳步发展为导向,提出了解决问题的若干对策,包括制定统一的信息标准规范电子病历、出台相关法律法规、提高技术手段确保电子病历的合法性和安全性。
Based on the modern medical record management model, some problems encountered in the implementation of EHR are expounded. For example, if the information standard is not uniform and the promotion of EHR is hindered, the legal status and legal nature of uncertainty can not lead to the direct evidence in the litigation Privacy and other threats. With the steady development of EHR as guidance, a number of countermeasures have been put forward to solve the problems, including formulating a unified information standard electronic medical record, promulgating relevant laws and regulations and enhancing the technical means to ensure the legitimacy and safety of EHRs.