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| Notice of the National Health Commission on Further Promoting the Construction for the Informationization of Medical Institutions with Electronic Medical Records as the Core | | 国家卫生健康委员会关于进一步推进以电子病历为核心的医疗机构信息化建设工作的通知 |
| (No. 20 [2018] of the General Office of the National Health Commission) | | （国卫办医发〔2018〕20号） |
| The health and family planning commissions of all provinces, autonomous regions, municipalities directly under the Central Government, and Xinjiang Production and Construction Corps: | | 各省、自治区、直辖市及新疆生产建设兵团卫生计生委： |
| For the purposes of comprehensively implementing the Healthy China Strategy, implementing the Opinions of the General Office of the State Council on Promoting the Development of “Internet plus Health Care,” and continuously promoting the construction for informatization of medical institutions with electronic medical records as the core (hereinafter referred to as “informatization of electronic medical records”), you are hereby notified of the relevant work requirements: | | 为全面实施健康中国战略，落实《国务院办公厅关于促进“互联网＋医疗健康”发展的意见》，持续推进以电子病历为核心的医疗机构信息化（以下简称电子病历信息化）建设，现将有关工作要求通知如下： |
| I. Raising the awareness of the significance of the construction for informatization of electronic medical records | | 一、提高对电子病历信息化建设工作重要性的认识 |
| In the report to the 19th CPC National Congress, General Secretary Xi Jinping emphasized the implementation of the Healthy China Strategy, the comprehensive establishment of a quality and efficient medical and health service system, and the improvement of the modern hospital management system. Premier Li Keqiang pointed out that there is great potentiality for utilizing “Internet +” to promote the improvement of the key areas of people's livelihood, and importance shall be attached to Internet and big data, among others, to improve the effectiveness of supervision. Promoting the construction for informationization of electronic medical records is of great significance for establishing and improving the modern hospital management systems, ensuring medical quality and safety, improving medical service efficiency, improving the public's experience in seeking medical advices, strengthening medical service supervision, and promoting the development of “smart hospitals,” among others. The local health administrative departments at all levels and various types of medical institutions at all levels shall further raise awareness, vigorously promote the construction for informatization of electronic medical records, and strive to provide comprehensive and full-cycle health services for the public. | | 习近平总书记在党的十九大报告中强调，实施健康中国战略，全面建立优质高效的医疗卫生服务体系，健全现代医院管理制度。李克强总理指出，运用“互联网＋”促进重点民生领域改善潜力巨大，要注重用互联网、大数据等提升监管效能。推进电子病历信息化建设，对建立健全现代医院管理制度，保障医疗质量和安全，提高医疗服务效率，改善群众就医体验，加强医疗服务监管，促进“智慧医院”发展等，具有重要意义。地方各级卫生健康行政部门和各级各类医疗机构要进一步提高认识，大力推进电子病历信息化建设，努力为人民群众提供全方位全周期的健康服务。 |
| II. Establishing and improving the working mechanism for the construction for informatization of electronic medical records | | 二、建立健全电子病历信息化建设工作机制 |
| The local health administrative departments at all levels and various types of medical institutions at all levels shall give top priority to the construction for informationization of electronic medical records, regard it as an important approach for promoting the construction of modern hospital management systems, enhance the core status of electronic medical records in the construction for informationization of medical institutions, establish and improve the sound long-term working mechanism, and continuously promote the relevant work continuously. The main responsible comrade of a medical institution shall be the first responsible person; the medical department shall be the leading department that is responsible for the construction for informatization of electronic medical records in an overall manner, coordinates with the information technology department, clinical department, pharmaceutical department, medical technology department, related functional departments, and other departments, strengthens the management and quality control, ensures that the construction for informatization of electronic medical records serves the clinical work, and guarantees the medical quality and medical safety; the clinical departments, pharmaceutical departments, medical technology departments, related functional departments and other departments shall be oriented to serving clinic, be patient-centered, put forward the needs of construction for informatization of electronic medical records in consideration of the work reality, and continuously improve the needs during the process of applying the information system; and the technology information department shall establish communication and coordination mechanism with all relevant departments, and strengthen the system development, maintenance, operation, and technical support according to the needs. | | 地方各级卫生健康行政部门和各级各类医疗机构要将电子病历信息化建设列为重点工作任务，将其作为推进现代医院管理制度建设的重要抓手，强化电子病历在医疗机构信息化建设过程中的核心地位，建立健全长效工作机制，持续深入推进有关工作。医疗机构主要负责同志是电子病历信息化建设的第一责任人；医务部门作为牵头部门，统筹负责电子病历信息化建设，协调信息技术部门、临床科室、药学部门、医技科室以及有关职能部门等其他部门，加强管理与质量控制，确保电子病历信息化建设服务临床工作，保障医疗质量和医疗安全；临床科室、药学部门、医技科室以及有关职能部门等其他部门要以服务临床为导向，以病人为中心，结合工作实际，提出电子病历信息化建设需求，并在应用信息系统过程中不断改进和完善需求；信息技术部门要建立与各相关部门的沟通协调机制，根据需求，加强系统开发、维护、运行和技术支持。 |
| III. Continuously strengthening the construction for informatization of electronic medical records | | 三、不断加强电子病历信息化建设 |
| 1. Realizing full coverage of the diagnosis and treatment services. On the basis of inpatient records, medical orders, and other systems, medical institutions shall give priority to the expansion of informatization of electronic medical records to outpatient, pharmacy, nursing, anesthesia, imaging, testing, pathology, and all other diagnosis and treatment respects, and comprehensively improve the informatization degree of clinical diagnosis and treatment. By 2020, hospitals at the third level shall realize comprehensive coverage of informatization of electronic medical records in the the respects of diagnosis and treatment services. | | （一）实现诊疗服务环节全覆盖。医疗机构要在住院病历、医嘱等系统基础上，优先将电子病历信息化向门诊、药学、护理、麻醉手术、影像、检验、病理等各诊疗环节拓展，全面提升临床诊疗工作的信息化程度。到2020年，三级医院要实现电子病历信息化诊疗服务环节全覆盖。 |
2. Maximizing the support function of clinical diagnosis and treatment decisions. Medical institutions shall be encouraged to embed clinical pathways, clinical diagnosis and treatment guidelines, technical specifications and medication guidelines, among others, into the information system in the construction for informatization of electronic medical records, to improve the standardized level of clinical diagnosis and treatment. The included clinical pathways, clinical diagnosis and treatment guidelines, technical specifications and medication guidelines shall be examined and approved by the medical quality management committees of medical institutions.
．．．．．． | | （二）发挥临床诊疗决策支持功能。鼓励医疗机构在电子病历信息化建设工作中，将临床路径、临床诊疗指南、技术规范和用药指南等嵌入信息系统，提高临床诊疗规范化水平。纳入的临床路径、临床诊疗指南、技术规范和用药指南等，应当经医疗机构医疗质量管理委员会审核同意。
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