临床医生对医院信息化建设的理解

诸明 赵晶晶 张维芯

摘要：目前，信息化在整个医疗系统中占据重要地位，医院信息化建设不仅体现了医院的医疗现代化，也为临床医生及患者提供了便利，更为医疗卫生事业提供了大量的统计、研究数据，促进卫生事业的进一步发展。作为一名临床医生，在参与信息化建设中发现，除了达到信息化本身的专业构架要求，临床一线以及患者的切身体验及需求对信息化建设的优化具有重要指导意义，发挥临床医生及患者的主观能动性解决一些细节问题对整个信息化建设具有促进作用。医疗事业最终服务的是大众，当今的医患关系紧张以及医患纠纷事件的不断增加，与医患之间沟通不充分、就医体验不佳有一定的关系，提高医务工作效率改善患者就医体验也是考验信息化建设是否成功的要点。总之，信息系统的适用主体是临床医生，但最终是要服务于患者群体。

关键词：医院信息化建设;临床需求;就医体验;医患关系

中图分类号：R391                                     文献标识码：B                                DOI：10.3969/j.issn.1006-1959.2019.04.009

文章編号：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

随着医院信息化建设的不断深入，围绕临床效率与医疗质量提升、学科建设与科研支持、医院精细化管理等方面的需求，加大信息化投入，增强信息化应用的产出，信息化建设已成为强院、立院之根本。众所周知，医院信息化建设经历三个阶段：①以财物管理为核心，实现医院管理信息化;②以电子病历为核心，实现临床管理信息化;③以信息交换为核心，实现区域卫生服务信息化。近年来，各类医院医疗应用系统大量涌现，其热点已由以费用管理核算为核心向着以电子病历为核心的现代化医院信息系统建设转变。为能更好、更准确地服务患者，需借助医疗信息化手段、病历的有效管理与查阅以及区域性数据共享来实现，其中，最先受益的是临床医生，最终服务于患者[1-3]。