【摘要】 目的 通过分析上海市医疗机构电子病历系统应用现状及其面临的问题，提出有针对性的优化策略，为推动以电子病历为核心的医院信息化建设提供参考。方法 采用随机抽样方法，对上海市54家已开展电子病历系统建设的二级及以上医疗机构进行调查，并结合关键知情人访谈，梳理电子病历系统建设现状及现存主要问题。结果 上海市医疗机构电子病历系统建设有序发展，智慧医院建设水平不断提升，但仍存在电子病历系统功能不完善、应用范围受限、数据质量不达标等问题。结论 应在质控标准和平台建设、培训推广力度、自主开发能力等方面进一步优化电子病历系统建设，使其成为提升医疗质量与效率的有力工具。更多还原

【Abstract】 Objective By analyzing the current status and challenges of electronic medical record(EMR) system construction in medical institutions in Shanghai,it proposes targeted optimization strategies to provide references for advancing hospital informatization centered on EMR systems. Methods A random sampling method was employed to survey 54 secondary and tertiary medical institutions in Shanghai that have implemented EMR systems. Key informant interviews were also conducted to examine the current status and major issues in EMR system development. Results The development of EMR systems in Shanghai’s medical institutions has progressed steadily,with continuous improvements in smart hospital development. However,challenges such as incomplete functionalities, limited application scope,and substandard data quality persist. Conclusion Further optimization of EMR system construction should focus on quality control standards,platform development,training and promotion efforts,and independent development capabilities to enhance its role as a robust tool for improving healthcare quality and efficiency.更多还原