The main differences between traditional medical records and electronic medical records are as follows:

active

1. Traditional medical records are passive, static and isolated, while electronic medical records are active, dynamic and related. Traditional medical records simply do not have the second function of electronic medical records, that is, they have no initiative and intelligence, and they cannot be related to relevant knowledge. Paper medical records can be read and supplemented with new contents, but there is no organic connection between the contents. The contents of medical records are completely out of touch with the actual state of patients, and the contents of medical records are electronic medical records.

[1] Without the connection of relevant knowledge, medical records can only be recorded in the same order. The revolutionary feature of electronic medical record is that the information it stores is no longer isolated and static, but related and dynamic. It is no longer just a piece of information, but a collection of knowledge. The new information will establish the necessary connection with all the existing information, change the structure, comprehensively analyze and judge the patient's status according to the existing knowledge, laws, rules and precedents, and actively remind the relevant doctors or patients; Put forward examination, treatment plan, etc. For example, the electronic medical record system for managing renal dialysis can record all relevant physiological indexes of patients and all previous dialysis information, which has been processed when entering the system. When the patient completes a dialysis treatment, the system will immediately put forward a set of detailed treatment plans or related suggestions according to the real-time detection of the instrument and the new examination results input by the doctor, including whether it is necessary to add examination items, whether it is necessary to use auxiliary drugs, and the measurement of drugs. After the doctor gives his own plan with reference to the plan provided by the system, the electronic medical record system will judge according to its stored knowledge, and will remind the doctor if there are contradictions or irregularities or violations of special principles. Doctors can ask contradictions about their principles and documents. If the doctor insists on his own plan and carries it out, and finally proves that the plan is effective, the electronic medical record system will learn the plan and save it as a precedent. This example shows that the recording function of traditional medical records is only one aspect of many functions of electronic medical records.

Complete and accurate

2. Traditional medical records cannot guarantee data integrity, while electronic medical records can ensure complete, accurate and timely access to information. This defect of traditional medical records comes from many aspects. First of all, the development of examination, treatment, monitoring and other technologies, including the development of management technology, are denying traditional medical records. According to the original intention of medical record management, all patients' related information should be centralized in the medical record for unified custody. X-rays were first managed separately from medical records, and pathological sections and smears were never classified as medical records. CT, B-ultrasound, nuclear magnetic resonance, perioperative monitoring, dialysis treatment, rehabilitation treatment and other imaging examinations obtained a lot of information. Apart from the medical records, only short reports or some short video materials entered the medical records, and some even left no specific information in the medical records except the doctor's advice and the course log. These information materials have been preserved. On the other hand, due to the limitation of traditional medical record paper media, it is impossible to save some materials, such as Doppler ultrasound video, with medical records. After the information system is put into use, information such as doctor's orders is stored in the computer. Although there are still printed pages bound to medical records, fewer and fewer people view paper information. Based on the above situation, it is not difficult to see from the general trend that the proportion of patient information saved in medical records to the total patient information is rapidly declining, and in the not-too-distant future, paper medical records will inevitably lose their significance. Secondly, the development of traffic has weakened people's regional concept. The reform of medical system enables patients to choose multiple hospitals for treatment. A person can see a doctor in different hospitals in Dongcheng or Xicheng, Beijing, or in hospitals in Shenzhen and Xi 'an. Using paper medical records, it is difficult for any hospital to get all the medical records of a patient from other hospitals. This difficulty is not limited to form. The examination results, idioms and quality control standards of different hospitals are basically unknown to doctors in other hospitals. Electronic medical records can comprehensively manage all kinds of information. It can be centralized management or decentralized management, and theoretically collect complete information of various decentralized management. For example, when a patient has a CT examination, the radiologist can see his image immediately, and the competent doctor can watch it in the ward at the same time through the electronic medical record system. However, at this time, because the radiologist has not given a diagnosis report, the relevant image data are mainly kept in the radiology department. After the diagnosis, the relevant information is automatically transmitted to the electronic medical record room through the computer network for permanent preservation. At this point, the doctor in charge only needs to know the differences in content and where the specific information is located, without electronic medical records.

I don't care if you want to. Electronic medical records of different hospitals can complete data transmission and exchange between hospitals through the network and necessary protocols and standards, and doctors can obtain comprehensive information, and they don't have to care about the storage location of medical records.

Knowledge association

3. Traditional medical records can't get the necessary interpretation and knowledge association. The so-called explanation is to explain the meaning. For medical records, interpretation includes two aspects: first, it is necessary to explain the actual meaning of terms used by different doctors or staff in different hospitals or the information recorded by testing instruments, so that different people can know its exact meaning correctly. For example, the medical records of one hospital need to be interpreted in another hospital. Non-medical personnel such as patients or insurance company personnel need to interpret medical records at any time. Second, explain the theoretical basis, significance, normal values and indications of unfamiliar terms or new concepts or new examinations, treatment items and new drugs caused by specialties, resources or new progress. Interpretation function needs the help of artificial intelligence technology, especially knowledge engineering. Knowledge association is of great significance to medical interns, senior doctors and junior doctors. Knowledge association is also helpful to solve the difficulty of reading medical records brought by specialization, and it is beneficial for doctors in low-level hospitals to enjoy the application of medical records in high-level hospitals. This kind of functional paper medical record is completely powerless.

Timely acquisition

4. Traditional medical records can't be obtained in time and can't be enjoyed. In addition to the inconvenience caused by medical records belonging to different hospitals, the medical records of the same hospital cannot be put in place in time due to reasons such as being borrowed, not filed or lost. The adoption of electronic medical records can completely change this situation. A patient's medical record can be obtained not only by many people at the same time, but also by different hospitals in different places. If a wireless network is connected, doctors can get medical records at any time, such as when traveling or meeting.