推进医疗信息化的目的是为医生诊疗和患者就医提供方便。近日，记者走访部分医院发现，患者就医时的“天书”病历已逐渐被电子化的“无书”取代，但问题是患者的处方和病历并无终端可查询，就医仍“一头雾水”。不透明的医疗信息化是否方便了医生开“大处方”？患者的知情权该如何保障？记者对此进行调查。

Promote the purpose of medical information for doctors and patients go to a doctor to provide convenient.recently,Reporter visited the hospital found that part,When go to a doctor of patients"A sealed book"Medical records has gradually be electronic"No book"replace,But the problem is the patient's prescription and medical records and no terminal can inquire,Doctor still"confused".Opaque medical information is convenient for a doctor"DaChuFang"?Patient's right to know how to guarantee?Journalists to investigate.

“现在连看病历的机会都没了” "Now even look at medical history chance is gone"

　　为了让患者就医更加顺利，近年来，宁夏开始以电子信息化代替手写诊疗流程，规范医生诊疗行为，希望实现诊疗信息的对称。然而，记者近日走访部分医院发现，推行医疗信息化后，患者对用药、费用等信息的知情权并无明显改善。

In order to let patients go to a doctor more smoothly,In recent years,Ningxia start with the electronic information instead of handwritten diagnosis and treatment process,Standard doctors behavior,Hope to achieve diagnosis information symmetry.however,Recently, reporters found that part of the hospital visit,After the implementation of the medical information,Patients to use/Information such as the cost of the right to know and no significant improvement.

　　“不太清楚医生开的什么药，也不知道多少钱 ， 应该有… …说不全。”在银川市中医院就诊的患者马宁拿着一张没有药名、价格的票据在等待缴费。对此，银川市中医院内科主任医师冯彩琴告诉记者，医院是两年前配置的信息化系统，患者想要在划价前了解用药和费用，只能询问医生。

"Don't know what the doctor prescribed medicine,Also don't know how many money , Should have... ...Said not all."Yinchuan in hospital of traditional Chinese medicine clinic patients marin with a piece of no medicines/The price of bill waiting for pay cost.this,Yinchuan hospital of traditional Chinese medicine medical chief physician FengCaiQin told reporters,The hospital was two years ago the configuration of the information system,Patients want to be in before to calculate understand medical and cost,Can only ask the doctor.

　　但是，患者一不小心被“处方”的情况仍然存在。前不久到银川市一家医院就诊的李姓患者告诉记者，因为割破手、流血不止到外科止血，原以为小病花不了多少钱，医生看后通过电脑开了处方，让我们去缴费就行了，缴费时仔细询问才发现，一种记不住名字的要打吊针的消炎药300多元。后来觉得太贵，要求医生重新开药，去掉了这种消炎药，仅服用了几十块钱的普通药，没过几天手上的伤也就好了。

but,Patients were carelessly"prescription"The situation still exist.Not long ago to yinchuan a hospital patients with those named li account told reporters,Because cut hand/Bleeding to surgical hemostasis,Thought ailment won't take much money,The doctor saw through the computer after open the prescription,Let's go to pay cost line,Payment shall carefully ask found,A kind of can't remember the name of the anti-inflammatory drugs is treated now with intravenous fluids to 300 yuan.Then think it's too expensive,Asked the doctor to prescribe,Remove the anti-inflammatory drugs,Only take dozens of dollars general medicine,Just after a few days hand injury is good.

　　此外，部分医院实现信息化后还存在门诊电子病历录入和查阅障碍。宁夏中医研究院儿科副主任医师赵颖说，病人很多，医生并不能及时录入每个人的电子病历，电脑里基本上只存处方，病情、病史等很少记录。

In addition,Part of the hospital after informatization there are clinic electronic medical records input and access barriers.Ningxia institute of traditional Chinese medicine of doctor of vice director of pediatric ZhaoYing said,Many patients,The doctor does not timely input everyone's electronic medical records,Computer basically having only prescription,condition/History records are less likely.

　　记者在很多医院的一楼大厅看到，没有设置终端方便患者查阅电子病历。几近于“无书”的就医经历让患者很无奈。患者于河潮说：“我无处调取之前的诊疗记录，到不同医院看病，医生有时重复进行同样的诊疗；在同一医院相隔不久看同样的病，之前开的药没吃完，缴费时才知道医生又开了相同的药。”

Reporters on the ground floor of the hall to see a lot of hospitals,No Settings terminal patients with convenient access to electronic medical records.Is close to"No book"The doctor has allowed patients is very helpless.Patients in the river tidal said:"I have no before obtaining the medical record,To a different hospital,Doctors sometimes repeated the same diagnosis and treatment;In the same hospital be apart soon see the same disease,Before the open medicine did not finish,Pay cost to know the doctor and open the same drug."

　　一些市民调侃道，“以前还有个看不太的潦草纸质病历，现在连看病历的机会都没了”。

Some people ridicule way,"Before there is a look not too much scribbled paper medical records,Now even look at medical history chance is gone".

“半信息化”难满足患者知情权 "Half the information"Difficult to meet the patients right to know

　　“之所以出现上述问题，原因是宁夏诊疗仍处于‘半信息化’状态。”自治区卫生厅医改办主任王维成介绍说，医疗信息化目的是使诊疗行为更加规范、透明，但目前仍在建设中。

"The reason appear afore-mentioned problems,The reason is still in the diagnosis and treatment‘Half the information’state."Autonomous region of health reform, do WangWeiCheng said,Medical information the purpose is to make medical behavior more standard/transparent,But there is still under construction.

　　据了解，宁夏从2008年开始使用 医疗信息化系统 ，大部分医院2010年开始统一配置设备。目前，医院诊疗只是建立在以电子病历为基础的信息化系统上，不是包括医学检验、影像信息和医院管理信息在内的现代化医院管理系统。

It is understood,Ningxia from 2008 began to use medical information system ,Most of the hospital in 2010 began to unified configuration equipment.At present,Hospital diagnosis is established on the basis of electronic medical records information system,Not include medical inspection/Image information and hospital management information, the modern hospital management system.

　　医疗“半信息化”难免出现一些弊端。王维成说，比如，医院即使设置终端系统也没有网络支撑为患者提供查询。卫生部门要求医生必须录入电子病历，由于录入规范的电子病历并没有减少医生的工作量，而且对一些老专家来说，输入电子病历有难度，造成患者的电子病历经常空白或极为简单。

medical"Half the information"Appears unavoidably some drawbacks.Wang Lin,Such as,The hospital even set terminal system also does not have the network support for patients with query.The health department asked the doctor must input electronic medical records,Due to the entry standard electronic medical records and did not reduce the workload of doctors,And for some old for experts,Input electronic medical records have difficulty,Result in patient's electronic medical records often blank or very simple.

　　记者采访发现，为了保证患者明白就医，很多医院保留了填写纸质病历等辅助手段。宁夏医科大学附属医院消化科医生王晶晶 说，目前医生在操作电脑的同时，会详细记录病情、病史和处方，给病人提供就医依据。

Reporters found that,In order to ensure that patients go to a doctor,Many hospitals retained the fill in paper records, such as supplementary means.Ningxia medical university affiliated hospital gastroenterology dept. The doctor WangJingJing said,At present the doctor in the operation of the computer at the same time,The illness will detailed records/History and prescription,Give patients a doctor basis.

　　但由于辅助措施基本要靠医生的个人主动性，保证患者知情权的效果并不理想。记者发现，由于使用电脑可顺利出具处方，一些医生避而不写病历或依然写“天书”病历，患者大多也不敢问。

But as a result of auxiliary measures basic must depend on the doctor's personal initiative,Ensure that patients right to know the effect is not ideal.Reporter discovery,Due to the use of the computer can be smoothly issue prescription,Some doctors avoid and don't write medical records or still write"A sealed book"Medical records,Most patients are afraid to ask.

信息不对称是医患纠纷重要原因 Information asymmetry is an important reason for medical disputes

　　医患之间信息不对称是引起医患纠纷的重要原因。专家认为，完善的医疗信息化可以满足患者的知情权，减少医患纠纷，多方促进医患之间的信息对称。

Between the medical information asymmetry is the important reason for the medical disputes caused by.Experts say,Perfect medical information can satisfy the patient's right to know,Reduce medical disputes,The patient to promote between the symmetry of information.

　　针对患者反映的“大处方”现象，王晶晶等医生认为，仍需监管部门、医院促进医生合理用药、合理施治，应尽量选择低层次的抗生素，减少不必要的检查。

According to patients reflects"DaChuFang"phenomenon,WangJingJing waiting for the doctor to think,Still need to regulators/Hospital doctors to promote rational drug use/By reasonable,Should as far as possible choose low levels of antibiotics,Reduce unnecessary inspection.

　　而在技术层面，王维成等人认为，宁夏目前正积极开发医疗价格监管信息系统，将药品、检查价格录入后，医生根据患者既往病史首先识别病人病情，如果出现“大处方”等不良诊疗情况，卫生监管部门会点评或约谈医生，情况严重将进行公示、警告。

And in the technical level,WangWeiCheng etc people think,Ningxia is currently actively develop medical price supervision information system,Will drug/Check the price after entry,The doctor according to patients with past history first recognition in the patient's condition,If there"DaChuFang"Diagnosis and treatment and other bad situation,Health supervision department will comment on or questioning the doctor,In severe cases will be public/warning.

　　另外，预计到2013年底，宁夏将在县以上医院建立完整的信息化系统。“卫生部门将通过与人社部门建立‘专网’，将就医信息接入‘专卡’社保卡，群众使用一张卡就能在门户网站查询本人的健康信息和终身就医记录。”

In addition,Is expected by the end of 2013,Ningxia will be at or above the county level hospital in the establishment of a complete information system."The ministry of health and the goalkeeper through social departments establish‘Private network’,The medical information access‘AD card’Social security card,People use a card can in the portal website of my health information and lifelong medical record."

　　在信息系化建设的同时，冯彩英等医生也建议，为了让患者在划价前知晓所开药物和价格，最好配备小型打印机，在医生诊疗的同时打印纸质处方，尊重患者的知情权和选择权。

In the information system construction of change at the same time,FengCaiYing until the doctor also suggested,In order to calculate in patients with known before the open drugs and price,The best equipped with small printer,The doctors at the same time printing paper prescriptions,Respect patients' right to know and option.

　　改善就医软环境也很重要。一些专家指出，一方面，医生必须告知患者电子病历和处方内容，避免不必要的药品浪费。另一方面，患者应主动提出知情要求，与医生共同商定相关诊疗方案，发现医生有违规行为应及时投诉。

Improved medical soft environment is also very important.Some experts say,On the one hand,The doctor patients must be informed about electronic medical records and prescription content,Avoid unnecessary waste of drugs.On the other hand,Patients should be offered to familiar with the requirements,And the doctor decided jointly related diagnosis and treatment plan,Doctors have found violations complaints should be timely.