EHR system for Healthcare services provided by Health Insurance

2023 Fiscal Year Final Research Report

• Project/Area Number: 21K10321
• Research Category: Grant-in-Aid for Scientific Research (C)
• Allocation Type: Multi-year Fund
• Section: 一般
• Review Section: Basic Section 58010:Medical management and medical sociology-related
• Research Institution: University of Tsukuba
• Principal Investigator: OHARA MAKOTO 筑波大学, 医学医療系, 教授 (80194273)
• Project Period (FY): 2021-04-01 – 2024-03-31
• Keywords: 保険診療 / 電子カルテ / 医療DX

Outline of Final Research Achievements

By verifying the EHR(Electronic Health Record) from the perspective of an appropriate insurance medical practice record, its deficiencies and weaknesses were identified, and efforts were made to improve the EHR. In particular, creating templates with mandatory items within the EHR was effective as a measure to prevent omissions by physicians, and 69 templates were created during the research period. And Clinical Paths were also verified. Medical DX(Digital Transformation) has managed to integrate the My Number Card with the health insurance card, but its utilization rate has not increased, and electronic prescriptions have not become widespread. As for the medical fee DX, there has been no progress. The reasons for this include the attempt to promote it without the standardization of underlying medical information and the widespread use of EHR and the lack of explanation to the public about benefits that outweigh the risks.

Free Research Field

医療情報学

Academic Significance and Societal Importance of the Research Achievements

従来の電子カルテは、診療録を単に電子保存するだけでなく、医療の効率性・医療の質の向上などの視点で、機能が追加され進歩してきたが、我が国の医療体制の基盤である保険診療の視点では、部門システムである医事会計システムにおいて算定という視点でのみ取り上げられてきた。今回、医療従事者の記載が保険診療に則り、適切に記載されているかの視点で電子カルテを検証し、その欠点・弱点を補うには必須項目記載を組み込んだテンプレートを各項目ごとに作成することが有効であることが実証できた。また現在進行中の医療DXについてその手法に警鐘を鳴らし、医療分野のDXにおいては情報基盤整備と広報・説明が重要であることを示した。