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首页> 美国卫生研究院文献>Annals of Family Medicine >Moving From Problem-Oriented to Goal-Directed Health Records
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Moving From Problem-Oriented to Goal-Directed Health Records

机译：从以问题为导向的病历转变为以目标为导向的病历

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摘要

Electronic health records (EHRs) have been in place for decades; however, most existing systems were designed in the prevailing disease- and payment-focused care paradigm that often loses sight of the goals, needs, and values of patients and clinicians. The goal-directed health care model was proposed more than 20 years ago, but no design principles have been developed for corresponding electronic record systems. Newly designed EHRs are needed to facilitate health care that is anchored by patient life and health goals. We explore the limitations of current EHRs and propose a blueprint for a new EHR design that may facilitate goal-directed health care. To reflect patient goals as a thread through the care continuum, we propose 5 major system functions for goal-directed health records based on the 8 characteristics of primary health care defined by the Institute of Medicine. We also discuss how new EHR functions could support goal-directed health care and how payment and quality measurement systems will need to be transformed. It may be possible for patient life and health goals to drive health care that is reinforced by a corresponding health record design; however, synchronized shifts must occur in the models of providing, documenting, and paying for health care.
机译：电子健康记录（EHR）已有数十年的历史了；但是，大多数现有系统是在流行的以疾病和付费为重点的护理范例中设计的，该范例常常忽视了患者和临床医生的目标，需求和价值。目标导向的医疗保健模型是20多年前提出的，但尚未为相应的电子记录系统开发设计原则。需要新设计的EHR来促进以患者生活和健康目标为基础的医疗保健。我们探索了当前电子病历的局限性，并提出了一种新的电子病历设计蓝图，该设计可以促进目标导向的医疗保健。为了将患者目标作为贯穿整个护理过程的一个线索，我们根据医学研究所定义的8种基本医疗保健特征，为目标导向的健康记录建议了5个主要系统功能。我们还将讨论新的EHR功能如何支持目标导向的医疗保健，以及如何改变支付和质量衡量系统。患者的生命和健康目标可能会通过相应的健康记录设计来加强医疗保健；但是，在提供，记录和支付医疗费用的模型中必须发生同步变化。

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