1. Electronic copy available at: http://ssrn.com/abstract=2383068

2. Electronic copy available at: http://ssrn.com/abstract=2383068
56
Â
ûñòóïàÿ 16 àïðåëÿ 2013 ãîäà íà ñîâåùàíèè â Ñàíêò-Ïå-
òåðáóðãå ïî ìîäåðíèçàöèè çäðàâîîõðàíåíèÿ â Ñåâåðî-
Çàïàäíîì ôåäåðàëüíîì îêðóãå, ìèíèñòð çäðàâîîõðàíå-
íèÿ ÐÔ Âåðîíèêà Ñêâîðöîâà ñîîáùèëà, ÷òî ê êîíöó äåêàáðÿ â
Ðîññèè ïëàíèðóåòñÿ çàïóñòèòü åäèíóþ ýëåêòðîííóþ ìåäèöèíñêóþ
êàðòó ïàöèåíòà [1].
 äðóãèõ ñòðàíàõ ìèðà ââåäåíèå ýëåêòðîííûõ ìåäèöèíñêèõ êàðò
(ÝÌÊ) íà÷àëîñü ãîðàçäî ðàíüøå, ïîýòîìó ó íàñ åñòü âîçìîæíîñòü
ïîñìîòðåòü, êàêèå ïîäâîäíûå êàìíè âñòðå÷àëèñü íà ýòîì ïóòè è â
êàêîé ìåðå óäàëîñü ïåðåâåñòè ìåäèöèíñêèå ó÷ðåæäåíèÿ íà
èñïîëüçîâàíèå ýëåêòðîííûõ äîêóìåíòîâ.
Èñòîðèÿ ýëåêòðîííûõ ìåäèöèíñêèõ äîêóìåí-
òîâ â ÑØÀ
Èäåÿ äîêóìåíòèðîâàíèÿ èíôîðìàöèè î ïàöèåíòå íå íà áóìàãå, à
â ýëåêòðîííîé ôîðìå — èäåÿ ýëåêòðîííîé ìåäèöèíñêîé êàðòû, ÝÌÊ
(Electronic Medical Record, EMR) — ïîÿâèëàñü â ÑØÀ â êîíöå 1960-õ
Í.À. ÕÐÀÌÖÎÂÑÊÀß,
ê.èñò.í., âåäóùèé ýêñïåðò ïî óïðàâëåíèþ äîêóìåíòàöèåé êîìïàíèè «ÝÎÑ», ýêñïåðò ÈÑÎ,
ã. Ìîñêâà, Ðîññèÿ, sspchram@tochka.ru
ÀÌÅÐÈÊÀÍÑÊÈÉ ÎÏÛÒ ÈÑÏÎËÜÇÎÂÀÍÈß
ÝËÅÊÒÐÎÍÍÛÕ ÌÅÄÈÖÈÍÑÊÈÕ
ÄÎÊÓÌÅÍÒÎÂ
ÓÄÊ 002.61
Õðàìöîâñêàÿ Í.À. Àìåðèêàíñêèé îïûò èñïîëüçîâàíèÿ ýëåêòðîííûõ ìåäèöèíñêèõ äîêóìåíòîâ
(Êîìïàíèÿ «Ýëåêòðîííûå îôèñíûå ñèñòåìû», ã. Ìîñêâà, Ðîññèÿ)
Àííîòàöèÿ: Îïèñûâàåòñÿ îïûò âíåäðåíèÿ ýëåêòðîííûõ ìåäèöèíñêèõ êàðò â ÑØÀ, êîòîðûé íàãëÿäíî
ïîêàçûâàåò, íàñêîëüêî ýòî íåïðîñòàÿ çàäà÷à. Äàæå òàêîé áîãàòîé ñòðàíå è ê òîìó æå ëèäåðó â ñôåðå
ñîâðåìåííûõ òåõíîëîãèé, êàê ÑØÀ, çà ñîðîê ëåò óñèëèé ïî ðàñïðîñòðàíåíèþ ÝÌÊ ïîëíîñòüþ ïåðåâåñòè
ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ íà èñïîëüçîâàíèå ýëåêòðîííûõ äîêóìåíòîâ ïîêà íå óäàëîñü. Äâèæåíèå âïåðåä âî
ìíîãîì ñâÿçàíî ñ óìåëûì ïðèìåíåíèåì êàê ïîëîæèòåëüíûõ, òàê è îòðèöàòåëüíûõ ñòèìóëîâ. Â ñòàòüå
ïðîàíàëèçèðîâàíû êàê äîñòèæåíèÿ, òàê ïðîáëåìû, ñ êîòîðûìè ñòîëêíóëèñü â ÑØÀ ïðè âíåäðåíèè ÝÌÊ.
Êëþ÷åâûå ñëîâà: ýëåêòðîííûå äîêóìåíòû, èíôîðìàöèîííûå ñèñòåìû, ìåäèöèíñêèå èíôîðìàöèîííûå ñèñòåìû,
ýëåêòðîííûå ìåäèöèíñêèå êàðòû, ÝÌÊ.
UDC 002.61
Khramtsovsky N. Electronic Health Records: the American experience (Electronic Office Systems LLP, Moscow,
Russia)
Abstract: The paper describes history and current trends in implementation of Electronic Health Records (EHR) in the
USA. The task isn't easy even for such a rich country and world's technological leader. After 40 years of efforts the
implementation of electronic records in health is still patchy. The progress is to a large extent due to wise application
of positive and negative stimuli. The paper discusses both the achievements and existing challenges related with EHRs.
Keywords: records management, electronic records, medical information systems, electronic medical record, EMR,
electronic health record, EHR.
© Í.À. Õðàìöîâñêàÿ, 2013 ã.

3. 57
ãîäîâ, êîãäà Ëàððè Âèä (Larry Weed) ïðåäëîæèë
ââåñòè â ìåäèöèíñêóþ ïðàêòèêó ïîíÿòèå «ïðî-
áëåìíî-îðèåíòèðîâàííîé ìåäèöèíñêîé êàðòû»
(Problem Oriented Medical Record).
 2009 ã. â ñâîåì èíòåðâüþ, ðàññêàçûâàÿ îá
èñòîðèè ÝÌÊ, Ë.Âèä îòìåòèë, ÷òî îí «ïûòàë-
ñÿ ñïðîåêòèðîâàòü è ðàçðàáîòàòü ñèñòåìó
ìåäèöèíñêîãî îáñëóæèâàíèÿ, â êîòîðîé áû
ïàöèåíòû áîëåå íå çàâèñåëè îò òåõ îãðàíè-
÷åííûõ ëè÷íûõ çíàíèé, êîòîðûå äîâåëîñü
ïîëó÷èòü îáñëóæèâàþùåìó èõ ìåäèöèíñêîìó
ïåðñîíàëó. Ñèñòåìû ìåäèöèíñêîãî îáñëóæè-
âàíèÿ äîëæíû íàïîìèíàòü òðàíñïîðòíûå
ñèñòåìû, â êîòîðûõ ïîëüçîâàòåëè, êîãäà
íóæíî, èñïîëüçóþò çíàíèÿ, çàôèêñèðîâàííûå
â âèäå êàðò, äîðîæíûõ çíàêîâ, êîìïüþòåðèçî-
âàííûõ óñòðîéñòâ äëÿ íàâèãàöèè è ò.ï. Ïàöè-
åíòû, ïîäîáíî ïóòåøåñòâåííèêàì, ñ äåòñòâà
äîëæíû áóäóò ïðèîáðåñòè íàâûêè, íåîáõîäè-
ìûå äëÿ íàâèãàöèè â òàêîé ñèñòåìå» [2].
Ïðåæäå âðà÷è îáû÷íî äîêóìåíòèðîâàëè ëèøü
äèàãíîçû è ïðîâåäåííîå èìè ëå÷åíèå. Âèä
ïðåäëîæèë èííîâàöèîííûé ïîäõîä, ïðåäóñìàò-
ðèâàâøèé ñîçäàíèå äîêóìåíòàöèè, êîòîðàÿ
áû ïîçâîëèëà òðåòüåé ñòîðîíå íåçàâèñèìî
ïðîâåðèòü ïðàâèëüíîñòü äèàãíîçà.
Äîñòàòî÷íî ðàíî ïîÿâèëèñü è ïðèìåðû
óäà÷íîãî âíåäðåíèÿ ïåðåäîâûõ òåõíîëîãèé.
Íà ÷åñòü ïåðâîïðîõîäöà ïðåòåíäóåò ðÿä
ó÷ðåæäåíèé, â òîì ÷èñëå äåòñêàÿ áîëüíèöà
Àêðîí (Akron Children's Hospital), êîòîðàÿ â
ñîòðóäíè÷åñòâå ñ ôèðìîé IBM ñîçäàëà êîì-
ïüþòåðèçîâàííóþ ñèñòåìó óïðàâëåíèÿ èíôîð-
ìàöèåé î ïàöèåíòàõ â 1962 ãîäó [3]. Â 1967
ãîäó Áîëüíèöà Ñâÿòûõ ïîñëåäíèõ äíåé (Latter
Day Saints Hospital) â øòàòå Þòà íà÷àëà
èñïîëüçîâàòü ïðîãðàììíîå îáåñïå÷åíèå
HELP (Health Evaluation through Logical Pro-
gramming — «Îöåíêà ñîñòîÿíèÿ çäîðîâüÿ íà
îñíîâå ëîãè÷åñêîãî ïðîãðàììèðîâàíèÿ»),
èìåâøåå îïðåäåëåííûå âîçìîæíîñòè ïî ïîä-
äåðæêå ïðèíÿòèÿ ðåøåíèé. Â 1969 ãîäó ìåäè-
öèíñêèé ôàêóëüòåò Ãàðâàðäñêîãî óíèâåðñèòå-
òà íà÷àë èñïîëüçîâàòü «Êîìïüþòåðèçîâàííóþ
àìáóëàòîðíóþ êàðòó» (Computer Stored
Ambulatory Record, COSTAR), à óíèâåðñèòåò
Äüþê (Duke University) íà÷àë ðàçðàáîòêó ñîá-
ñòâåííîé ÝÌÊ-ñèñòåìû «Ìåäèöèíñêàÿ êàðòà»
(The Medical Record, TMR) [4].
 íà÷àëå 1970-õ ãîäîâ â ã. Õåìïäåíå, øòàò
Ìåéí (Hampden, Maine) Ãàðîëüä Êðîññ
(Harold Cross), Äæîí Áüåðí (John Bjorn) è
×àðëüç Áóðãåð (Charles Burger) ñîçäàëè
ðåàëüíî ðàáîòàþùóþ «ïðîáëåìíî-îðèåíòè-
ðîâàííóþ ìåäèöèíñêóþ ïðàêòèêó». Îíè ðàç-
ðàáîòàëè è âíåäðèëè â ñâîåé ïðàêòèêå
ìîäåëü, êîòîðàÿ ïðîäåìîíñòðèðîâàëà âîç-
ìîæíîñòè ïðåäëîæåííîãî Âèäîì ïîäõîäà. Êàê
âñïîìèíàåò îäèí èç àìåðèêàíñêèõ ñïåöèàëè-
ñòîâ: «Ýòî áûëà ïîðàçèòåëüíàÿ äåìîíñòðàöèÿ
äîñòîèíñòâ ïðîáëåìíî-îðèåíòèðîâàííîé
ìåäèöèíñêîé êàðòû. ß, íàïðèìåð, ïîìíþ, ÷òî
îíè íàñòîëüêî õîðîøî îòñëåæèâàëè ïðîáëå-
ìû, ñ êîòîðûìè ñòàëêèâàëèñü èõ ïàöèåíòû, ÷òî
ìîãëè èçâëå÷ü âñþ äîêóìåíòàöèþ ïàöèåíòà ïî
ýòîé ïðîáëåìå è ïåðèîäè÷åñêè ïðèãëàøàëè
ñïåöèàëèñòîâ äëÿ àíàëèçà ýòèõ äîêóìåíòîâ è
îöåíêè òîãî, íàñêîëüêî ïðàâèëüíî ïðîâîäè-
ëîñü ëå÷åíèå. Ýòî áûë âïå÷àòëÿþùèé ïîäõîä,
îáåñïå÷èâàâøèé ïîâûøåíèå êà÷åñòâà ìåäè-
öèíñêèõ óñëóã…».
Íîâûå èäåè áûëè ïîääåðæàíû òàêèìè
èçâåñòíûìè ëþäüìè, êàê ðåäàêòîð «Ìåäèöèí-
ñêîãî æóðíàëà Íîâîé Àíãëèè» (New England
Journal of Medicine, NEJM) Ôðàíö Èíãëôàé-
íäåð (Franz Inglefinger), îïóáëèêîâàâøèé â
1968 ãîäó â ñâîåì æóðíàëå ïåðâóþ ñòàòüþ ïî
äàííîìó âîïðîñó, íàïèñàííóþ Âèäîì [5]. Ïî
ñóòè äåëà, â ñòàòüå ïðåäëàãàëàñü îïðåäåëåí-
íàÿ àðõèòåêòóðà ÝÌÊ, îðèåíòèðîâàííàÿ íà
èìåþùèåñÿ ó ïàöèåíòà ïðîáëåìû. Áîëüøîå
çíà÷åíèå èìåëà ïîääåðæêà ñî ñòîðîíû òîãäàø-
íèõ ëèäåðîâ àìåðèêàíñêîé ìåäèöèíû —
ðàáîòàâøèõ â Àòëàíòå Óèëëèñà Õåðñòà (Willis
Hurst) è Êåííåòà Óîêåðà (Kenneth Walker).
Õåðñò íå òîëüêî âîçãëàâëÿë ñ÷èòàþùèéñÿ
îäíèì èç ëó÷øèõ â ñòðàíå ìåäèöèíñêèé
ôàêóëüòåò Óíèâåðñèòåòà Ýìîðè (Emory Univer-
sity School of Medicine, http://med.emory.edu/
/main/about/index.html), íî è áûë àâòîðîì

4. 58
ðÿäà îñíîâíûõ ó÷åáíèêîâ.  1971 ãîäó îí
îïóáëèêîâàë ñòàòüþ â ïîääåðæêó èäåé Âèäà,
à ïîçäíåå îðãàíèçîâàë ïî ýòîé òåìàòèêå äâå
êðóïíûå êîíôåðåíöèè [6].
 1970 ãîäó íà÷àëà ðàáîòàòü ìåäèöèíñêàÿ
èíôîðìàöèîííàÿ ñèñòåìà Òåõíèêîí (Techni-
con Medical Information Management System,
TDS). Ýòîò ïðîåêò, íà÷àòûé ôèðìîé Ëîêõèä
(Lockheed), áûë ñ áîëüøèì óñïåõîì âíåäðåí
â êàëèôîðíèéñêîé áîëüíèöå El Camino è
ðàñöåíèâàëñÿ êàê ðåâîëþöèîííàÿ êîìïüþòå-
ðèçîâàííàÿ ñèñòåìà, îáåñïå÷èâàâøàÿ ââîä
ìåäèöèíñêèõ íàçíà÷åíèé.  1972 ãîäó Èíñòè-
òóò Ðåäæåíñòðàéôà (Regenstreif Institute,
http://www.regenstrief.org) ñîçäàë, êàê ñ÷èòà-
þò íåêîòîðûå, ïåðâóþ ñèñòåìó óïðàâëåíèÿ
ìåäèöèíñêèìè äîêóìåíòàìè [7].
ÝÌÊ-ñèñòåìû ðàçâèâàëèñü íà ôóíäàìåíòå
óñïåøíûõ íàó÷íûõ ýêñïåðèìåíòîâ ñ ñèñòåìà-
ìè ââîäà è îáðàáîòêè äàííûõ, ñïîñîáíûìè
óïîðÿäî÷èâàòü è õðàíèòü îãðîìíûå îáúåìû
èíôîðìàöèè è áûñòðî âûäàâàòü çàïðîøåííûå
ìåäèöèíñêèå äàííûå. Îäíàêî, íåñìîòðÿ íà
îòäåëüíûå ñëó÷àè èñïîëüçîâàíèÿ ÝÌÊ ñ
1970-õ ãîäîâ, â îñíîâíîì â ãîñóäàðñòâåííûõ
ãîñïèòàëÿõ è â ïåðåäîâûõ ìåäèöèíñêèõ ó÷ðåæ-
äåíèÿõ, ýëåêòðîííûå ìåäèöèíñêèå äîêóìåíòû
äëèòåëüíîå âðåìÿ íå íàõîäèëè ìàññîâîãî
ïðèìåíåíèÿ.
 1980-õ ãîäàõ Äåïàðòàìåíò ïî äåëàì
âåòåðàíîâ (Veterans Administration) ââåë â
ýêñïëóàòàöèþ ñâîþ «Äåöåíòðàëèçîâàííóþ
áîëüíè÷íóþ êîìïüþòåðíóþ ñèñòåìó» (Decen-
tralized Computer Hospital Program, DCHP),
êîòîðàÿ ïðîäîëæàåò èñïîëüçîâàòüñÿ è ñåé÷àñ
— ñ 1994 ãîäà ïîä íàçâàíèåì VistA (Veterans
Health Information Systems and Technology
Architecture — «Àðõèòåêòóðà ìåäèöèíñêèõ
èíôîðìàöèîííûõ ñèñòåì è òåõíîëîãèé äëÿ
âåòåðàíîâ») [8]. Â 1988 ãîäó êîðïîðàöèÿ Sci-
ence Applications International Corporation
(SAIC) ïîëó÷èëà ìèëëèàðäíûé ãîñóäàðñòâåí-
íûé êîíòðàêò íà ñîçäàíèå «Ñèñòåìû êîì-
ïëåêñíîãî ìåäèöèíñêîãî îáñëóæèâàíèÿ»
(Composite Health Care System, CHCS) äëÿ
âñåõ âîåííî-ìåäèöèíñêèõ öåíòðîâ, è ýòî
ðåøåíèå äî ñèõ ïîð ÿâëÿåòñÿ îñíîâîé ÝÌÊ-
ñèñòåìû Ìèíèñòåðñòâà îáîðîíû ÑØÀ [9].
 1990-õ ãîäàõ ñòàëè ïîÿâëÿòüñÿ íîâûå
ïðîãðàììíûå ðåøåíèÿ. Â 1992 ãîäó ôèðìà
Epic âûïóñòèëà ïåðâóþ ÝÌÊ-ñèñòåìó ïîä Win-
dows, à êîìïàíèÿ Allscripts ïðåäëîæèëà ïåð-
âîå ðåøåíèå, ïîääåðæèâàþùåå âûïèñêó âðà-
÷àìè ýëåêòðîííûõ ðåöåïòîâ. Àâòîðèòåòíûé
Èíñòèòóò ìåäèöèíû (Institute of Medicine, IOM)
îïóáëèêîâàë ñâîå ìíåíèå î òîì, ÷òî ÝÌÊ-
ñèñòåìû ÿâëÿþòñÿ áóäóùèì âûñîêîêà÷åñòâåí-
íûõ ìåäèöèíñêèõ óñëóã, è ïðèçâàë ïîñòàâùè-
êîâ ìåäèöèíñêèõ óñëóã âñåðüåç çàäóìàòüñÿ î
âíåäðåíèè òàêèõ ñèñòåì.
 2000-õ ãîäàõ ïðîäîëæèëîñü íàðàùèâà-
íèå ôóíêöèîíàëüíûõ âîçìîæíîñòåé ÝÌÊ-
ñèñòåì, êîòîðûå ñòàëè ïðåâðàùàòü â èíòåðàê-
òèâíûõ «êîìïàíüîíîâ» âðà÷åé è ïîñòàâùèêîâ
ìåäèöèíñêèõ óñëóã.
 2009 ãîäó Ïðåçèäåíò Á. Îáàìà äàë ðàñïî-
ðÿæåíèå ñîçäàòü ê 2014 ãîäó îáùåíàöèîíàëü-
íóþ ÝÌÊ-ñèñòåìó. Áûë ïðèíÿò çàêîí îá îçäîðî-
âëåíèè ýêîíîìèêè è ðåèíâåñòèöèÿõ (American
Recovery and Reinvestment Act of 2009), 13-é
ðàçäåë êîòîðîãî èçâåñòåí êàê Çàêîí îá èñïîëü-
çîâàíèè ìåäèöèíñêèõ èíôîðìàöèîííûõ òåõíîëî-
ãèé â êëèíè÷åñêîé è ýêîíîìè÷åñêîé äåÿòåëüíî-
ñòè (Health Information Technology for Clinical
and Economic Health Act, HITECH). Çàêîí
HITECH íàïðàâëåí íà ïðîäâèæåíèå è ðàñøèðå-
íèå èñïîëüçîâàíèÿ ÈÒ-òåõíîëîãèé â ìåäèöèíå.
Ñ ýòîãî ìîìåíòà èíòåðåñ ðóêîâîäñòâà
ãîñóäàðñòâà è äåëîâûõ êðóãîâ ê ïðîãðåññó â
îáëàñòè âíåäðåíèÿ ìåäèöèíñêèõ ÈÒ-òåõíîëî-
ãèé íà÷àë áûñòðî ðàñòè. Çàêîí HIPAA ââåë
ñòèìóëèðóþùèå âûïëàòû ÷åðåç ïðîãðàììû
Medicare è Medicaid òåì ïîñòàâùèêàì ìåäè-
öèíñêèõ óñëóã, êîòîðûå èñïîëüçóþò ñåðòèôè-
öèðîâàííûå ÝÌÊ-ñèñòåìû äëÿ äîñòèæåíèÿ
ðÿäà îãîâîðåííûõ óëó÷øåíèé â ìåäèöèíñêîì
îáñëóæèâàíèè, à Ìèíèñòåðñòâî çäðàâîîõðà-
íåíèÿ (Department of Health and Human Servi-
ces) óñòàíîâèëî êðèòåðèè «êîíñòðóêòèâíîãî
èñïîëüçîâàíèÿ» ÝÌÊ-ñèñòåì.

5. 59
Òàêèì îáðàçîì, èñòîðèÿ èíôîðìàòèçàöèè
àìåðèêàíñêîãî çäðàâîîõðàíåíèÿ íàñ÷èòûâàåò
áîëåå ïÿòèäåñÿòè ëåò, è, õîòÿ çà ýòî âðåìÿ
îáúåìû èñïîëüçîâàíèÿ ýëåêòðîííûõ ìåäèöèí-
ñêèõ äîêóìåíòîâ íåóêëîííî ðîñëè, ãîâîðèòü î
ïîëíîì ïåðåõîäå íà ýëåêòðîííûå òåõíîëîãèè
íå ïðèõîäèòñÿ.
Ïîëîæåíèå äåë ñ èñïîëüçîâà-
íèåì ýëåêòðîííûõ ìåäèöèí-
ñêèõ äîêóìåíòîâ â 2009 ãîäó
Ïî äàííûì ðÿäà îïðîñîâ, ïîëîæåíèå äåë
ñ ýëåêòðîííûìè ìåäèöèíñêèìè äîêóìåíòàìè â
ÑØÀ â 2009 ãîäó áûëî ñëåäóþùåå [10]:
• ïîëíîñòüþ èëè ÷àñòè÷íî ÝÌÊ-ñèñòåìû
èñïîëüçîâàëè â ñâîåé ïðàêòèêå 48,3% âðà÷åé;
• 21,8% âðà÷åé ñîîáùèëè î òîì, ÷òî èõ
ñèñòåìû óäîâëåòâîðÿþò ìèíèìàëüíûì (áàçî-
âûì) òðåáîâàíèÿì, è ëèøü 6,9% âðà÷åé èñïîëü-
çîâàëè ïîëíîôóíêöèîíàëüíûå ÝÌÊ-ñèñòåìû.
Êîìïàíèÿ Medscape îïðîñèëà áîëåå 3700
ñïåöèàëèñòîâ, â òîì ÷èñëå 1800 âðà÷åé è 500
ìåäñåñòåð [11]. Áûëè ïîëó÷åíû ñëåäóþùèå
ðåçóëüòàòû:
•  êðóïíûõ ìåäèöèíñêèõ ó÷ðåæäåíèÿõ
ÝÌÊ-ñèñòåìû èñïîëüçîâàëèñü ÷àùå (ñâûøå
50%), ÷åì â ìåëêèõ âðà÷åáíûõ ïðàêòèêàõ
(27,5%). Â öåëîì ÝÌÊ-ñèñòåìàìè ïîëüçîâà-
ëèñü 37,9% îïðîøåííûõ. Åùå 24,8% ñîáèðà-
ëèñü âíåäðèòü òàêèå ñèñòåìû â áëèæàéøèå
ãîä—äâà.
• Íà ðûíêå ÝÌÊ-ñèñòåì íå áûëî ÿâíîãî
ëèäåðà. Ìàêñèìàëüíóþ äîëþ ðûíêà èìåëà
ñèñòåìà Epic (11,3%).
• Áîëüøèíñòâî îïðîøåííûõ áûëî óäîâëå-
òâîðåíî èìåþùåéñÿ ó íèõ ÝÌÊ-ñèñòåìîé
(69,3%) è ãîòîâî áûëî ðåêîìåíäîâàòü åå êîë-
ëåãàì. Â òî æå âðåìÿ ïî÷òè òðåòü (30,7%)
ñâîþ ñèñòåìó íå ïîðåêîìåíäîâàëè áû. Èç
÷èñëà òåê, êòî áûë íå óäîâëåòâîðåí ñóùåñò-
âóþùåé ñèñòåìîé, ëèøü 17,2% ñîîáùèëè î
íàìåðåíèè åå çàìåíèòü.
Äàííûå ãðóïïèðîâàëèñü ïî êîíêðåòíûì
ïðîäóêòàì, è íåóäîâëåòâîðåííûìè îêàçàëîñü
ñâûøå òðåòè ïîëüçîâàòåëåé íåñêîëüêèõ
ñèñòåì, èñïîëüçóåìûõ êðóïíûìè ëå÷åáíûìè
ó÷ðåæäåíèÿìè.
• Ïî ïÿòèáàëëüíîé øêàëå ëèøü îäíà
ñèñòåìà ïîëó÷èëà îáùóþ îöåíêó âûøå
«÷åòâåðêè», è òðè ñèñòåìû áûëè îöåíåíû íèæå
«òðîéêè».
• Ïåðâîíà÷àëüíàÿ öåíà ÝÌÊ-ñèñòåì â
ðàñ÷åòå íà îäíîãî âðà÷à êîëåáàëàñü â øèðî-
êîì äèàïàçîíå (8% îïðîøåííûõ ñîîáùèëè î
öåíå ðàáî÷åãî ìåñòà áîëåå 50 òûñÿ÷ äîëëà-
ðîâ, à 20,6% — î öåíå ìåíåå 10 òûñÿ÷ äîë-
ëàðîâ).  40% ñëó÷àåâ ñòîèìîñòü íå ïðåâû-
øàëà 35 òûñÿ÷ äîëëàðîâ.
Ïðîãðåññ, äîñòèãíóòûé
ê 2012 ãîäó
 áþëëåòåíå «Îáúåìû èñïîëüçîâàíèÿ è
õàðàêòåðèñòèêè ýëåêòðîííûõ ìåäèöèíñêèõ
äîêóìåíòîâ âðà÷åáíûìè ïðàêòèêàìè ÑØÀ,
ðàñïîëàãàþùèìèñÿ â ñòàöèîíàðíûõ ïîìåùå-
íèÿõ, â 2001–2012 ãîäàõ» îòìå÷àåòñÿ, ÷òî â
2012 ãîäó â Ñîåäèíåííûõ Øòàòàõ ïî÷òè 72%
âðà÷åé, ðàáîòàþùèõ â ñòàöèîíàðíûõ ïîìåùå-
íèÿõ, èñïîëüçîâàëè ýëåêòðîííûå ìåäèöèíñêèå
äîêóìåíòû èëè ýëåêòðîííûõ ìåäèöèíñêèå
êàðòû (â 2009 ãîäó èõ èñïîëüçîâàëè 48% âðà-
÷åé). Ïî÷òè 40% ïðèìåíÿþò ýëåêòðîííûå äîêó-
ìåíòíûå ñèñòåìû, ñîîòâåòñòâóþùèå ôåäåðàëü-
íûì òðåáîâàíèÿì ê áàçîâûì ôóíêöèîíàëüíûì
âîçìîæíîñòÿì (â 2009 ãîäó — 22%) [12].
×èñëî âðà÷åé, â òîé èëè èíîé ôîðìå
èñïîëüçóþùèõ ýëåêòðîííûå ìåäèöèíñêèå
äîêóìåíòû, âûðîñëî ïî ñðàâíåíèþ ñ 2011 ãî-
äîì íà 26% (ðèñ. 1).
×èñëî âðà÷åé, èñïîëüçóþùèõ ñèñòåìû, óäî-
âëåòâîðÿþùèå áàçîâûì ôåäåðàëüíûì òðåáî-
âàíèÿì (è òàêèì îáðàçîì ïîäïàäàþùèõ ïîä
ôåäåðàëüíûå ïðîãðàììû ïîîùðåíèÿ èñïîëü-
çîâàíèÿ ýëåêòðîííûõ ìåäèöèíñêèõ äîêóìåíòîâ
— Í.Õ.), âûðîñëî ïî ñðàâíåíèþ ñ 2011 ãîäîì
íà 17%.
Ñðåäè äðóãèõ âûâîäîâ â áþëëåòåíå òàêæå
îòìå÷àåòñÿ ñëåäóþùåå: äâå òðåòè ïðàêòèêóþ-
ùèõ â ñòàöèîíàðíûõ ïîìåùåíèÿõ âðà÷åé
ñîîáùèëî, ÷òî îíè ïëàíèðóþò îáðàòèòüñÿ èëè

6. 60
óæå îáðàòèëèñü çà ñòèìóëèðóþùèìè âûïëàòà-
ìè, ïîîùðÿþùèìè «îñìûñëåííîå» èñïîëüçî-
âàíèå ýëåêòðîííûõ äîêóìåíòîâ, â ñîîòâåò-
ñòâèè ñ óñòàíîâëåííûìè ñòàíäàðòàìè:
• ïðîöåíò âðà÷åé, â òîé èëè èíîé ñòåïåíè
ïðèìåíÿþùèõ ýëåêòðîííûå ìåäèöèíñêèå äîêó-
ìåíòû, âàðüèðóåòñÿ îò øòàòà ê øòàòó — îò
54% â Íüþ-Äæåðñè äî íàèâûñøåãî óðîâíÿ â
89% â øòàòå Ìàññà÷óñåòñ.
• ÷òî êàñàåòñÿ èñïîëüçîâàíèÿ ñåðòèôèöèðî-
âàííûõ ñèñòåì, ñîîòâåòñòâóþùèõ áàçîâûì
ôóíêöèîíàëüíûì òðåáîâàíèÿì, òî õóäøèå ïîêà-
çàòåëè ó ôåäåðàëüíîãî îêðóãà Êîëóìáèÿ (22%)
è Ëóèçèàíû (25%). Ëèäåðàìè çäåñü ÿâëÿþòñÿ
øòàòû Âèñêîíñèí (71%) è Ìèííåñîòà (67%).
Åùå â îäíîì áþëëåòåíå Íàöèîíàëüíîãî
öåíòðà ìåäèöèíñêîé ñòàòèñòèêè îá èñïîëüçîâà-
íèè ÝÌÊ-ñèñòåì àìåðèêàíñêèìè âðà÷àìè â
2011 ãîäó îòìå÷àëîñü, ÷òî, ñ òî÷êè çðåíèÿ âðà-
÷åé, îñíîâíûìè äîñòîèíñòâàìè ÝÌÊ áûëè [13]:
• ïîâûøåíèå â öåëîì êà÷åñòâà ìåäèöèí-
ñêèõ óñëóã (74%);
• âîçìîæíîñòü óäàëåííîãî äîñòóïà ê ìåäè-
öèíñêîé èíôîðìàöèè (74%);
• ïîëó÷åíèå ïðåäóïðåæäåíèé î êðèòè÷åñ-
êèõ çíà÷åíèÿõ ðåçóëüòàòîâ ëàáîðàòîðíûõ
èññëåäîâàíèé (52%);
• ïîëó÷åíèå ïðåäóïðåæäåíèé î âîçìîæíî
îøèáî÷íûõ íàçíà÷åíèÿõ (43%);
• íàïîìèíàíèÿ î ïðèíÿòèè ïðîôèëàêòè÷åñ-
êèõ ìåð (40%);
• íàïîìèíàíèÿ î òîì, ÷òî óñëóãè íàäî îêà-
çûâàòü â ñîîòâåòñòâèè ñ ïðèíÿòûìè ñòàíäàð-
òàìè êëèíè÷åñêîé ïðàêòèêè (38%);
• ñîêðàùåíèå êîëè÷åñòâà ëàáîðàòîðíûõ
àíàëèçîâ è òåñòîâ áëàãîäàðÿ äîñòóïíîñòè
äàííûõ ðàíåå âûïîëíåííûõ àíàëèçîâ (30%);
• ïîäñêàçêè î òîì, êàêèå àíàëèçû íåîáõî-
äèìî ñäåëàòü (29%);
• óïðîùåíèå ïðÿìîãî âçàèìîäåéñòâèÿ ñ
ïàöèåíòàìè (25%).
Ïðè ýòîì ñïåöèàëèñòû â îáëàñòè ìåäèöèí-
ñêîé èíôîðìàòèçàöèè àêòèâíî îáñóæäàþò è
èìåþùèåñÿ ïðîáëåìû, â òîì ÷èñëå è âåñüìà
áîëåçíåííûé âîïðîñ î òîì, ïî÷åìó ìåäèöèí-
ñêîé îòðàñëè òàê è íå óäàëîñü äîñòè÷ü ðåàëü-
íîé è îùóòèìîé ýêîíîìèè ôèíàíñîâûõ
ñðåäñòâ. Òàê, â 2005 ãîäó èññëåäîâàòåëè êîð-
ïîðàöèè RAND (àìåðèêàíñêàÿ íåêîììåð÷åñ-
êàÿ îðãàíèçàöèÿ, ñ÷èòàþùàÿñÿ âåäóùèì öåíò-
ðîì ñòðàòåãè÷åñêèõ èññëåäîâàíèé, îñîáåííî
â îáëàñòè íàöèîíàëüíîé áåçîïàñíîñòè, îáî-
ðîíû è ÈÒ-òåõíîëîãèé — Í.Õ.) ñ÷èòàëè, ÷òî
ïåðåõîä íà èñïîëüçîâàíèå ýëåêòðîííûõ ìåäè-
Ðèñ. 1. Äèíàìèêà èçìåíåíèÿ ïî ãîäàì äîëè ðàáîòàþùèõ â ñòàöèîíàðíûõ ïîìåùåíèÿõ
àìåðèêàíñêèõ âðà÷åé, èñïîëüçóþùèõ ýëåêòðîííûå ìåäèöèíñêèå äîêóìåíòû (äàííûå çà
2011–2012 ãîäû ïðåäâàðèòåëüíûå, îñíîâàííûå òîëüêî íà ðåçóëüòàòàõ ïî÷òîâîãî îïðîñà)

7. 61
öèíñêèõ äîêóìåíòîâ ìîæåò åæåãîäíî ýêîíî-
ìèòü äëÿ ñèñòåìû çäðàâîîõðàíåíèÿ ÑØÀ ïî
ìåíüøåé ìåðå 81 ìèëëèàðä äîëëàðîâ [14].
Àðòóð Êåëëåðìàí è Ñïåíñåð Äæîíñ â
ñòàòüå «×òî ïîòðåáóåòñÿ, ÷òîáû äîñòè÷ü ïîêà
åùå íåâûïîëíåííûõ îáåùàíèé çäðàâîîõðàíå-
íèÿ ïî èíôîðìàöèîííûì òåõíîëîãèÿì», îïó-
áëèêîâàííîé â ÿíâàðå 2013 ãîäà, îòìå÷àþò,
÷òî, «õîòÿ èíôîðìàöèîííûå òåõíîëîãèè ñòàëè
øèðå ïðèìåíÿòüñÿ â ìåäèöèíå, îäíàêî êà÷åñò-
âî è ýôôåêòèâíîñòü îáñëóæèâàíèÿ ïàöèåíòîâ
ëèøü íåçíà÷èòåëüíî óëó÷øèëèñü. Èññëåäîâàíèÿ
ýôôåêòèâíîñòè ïðèìåíåíèÿ ÈÒ â çäðàâîîõðà-
íåíèè äàëè íåîäíîçíà÷íûå ðåçóëüòàòû» [15].
Êåëëåðìàí è Äæîíñ âûäåëÿþò íåñêîëüêî
àñïåêòîâ, ãäå ýëåêòðîííûå ìåäèöèíñêèå äîêó-
ìåíòû íå ïðîÿâèëè ñåáÿ òàê, êàê ïðåäïîëàãà-
ëîñü.
Âî-ïåðâûõ, âðà÷è íå âíåäðèëè ýëåêòðîí-
íûå äîêóìåíòû íàñòîëüêî øèðîêî, êàê ýòî
îæèäàëîñü. Èññëåäîâàòåëè èç RAND ðàññ÷è-
òûâàëè íà òî, ÷òî îêîëî 90% âðà÷åé ïåðåâå-
äóò ñâîè äîêóìåíòû â ýëåêòðîííûé âèä. Îäíà-
êî âíåäðåíèå øëî ãîðàçäî áîëåå ìåäëåííû-
ìè òåìïàìè: òîëüêî îêîëî ïîëîâèíû âðà÷åé
ïîëíîñòüþ ïåðåøëè íà èñïîëüçîâàíèå ýëåê-
òðîííûõ äîêóìåíòîâ. Äëÿ áîëüíèö ýòîò ïîêà-
çàòåëü íèæå 30% (ðèñ. 2) [16].
Íåäàâíî ñâîé î÷åðåäíîé, 2012 ãîäà, îò÷åò
îá ÝÌÊ-ñèñòåìàõ, ïîääåðæèâàþùèõ ýëåêòðîí-
íûå ìåäèöèíñêèå êàðòû (Electronic Health
Record, EHR), âûïóñòèëà êîìïàíèÿ Medscape.
Äîêóìåíò ïîä íàçâàíèåì «Îò÷åò îá ÝÌÊ-ñè-
ñòåìàõ 2012: Âðà÷è îöåíèâàþò âåäóùèå ÝÌÊ-
ñèñòåìû» ïîäãîòîâëåí íà îñíîâàíèè ðåçóëüòà-
òîâ îïðîñà 21 òûñÿ÷è âðà÷åé 25 ñïåöèàëèçà-
öèé [18].  îò÷åòå ïðèâåäåíû ðåéòèíã ÝÌÊ-
ñèñòåì, îöåíêà âðà÷àìè âëèÿíèÿ ÝÌÊ íà èõ
ïðàêòèêó è íà âçàèìîîòíîøåíèÿ ïàöèåíò-
âðà÷, óäîâëåòâîðåííîñòü ïîääåðæêîé, îêàçû-
âàåìîé ïîñòàâùèêàìè ÝÌÊ-ñèñòåì, è ðÿä äðó-
ãèõ êëþ÷åâûõ èíäèêàòîðîâ ðûíêà ÝÌÊ (ðèñ. 3).
Îñíîâíûå âûâîäû ïî èòîãàì îïðîñà áûëè
ñäåëàíû ñëåäóþùèå:
• 82% îïðîøåííûõ ëèáî óæå èñïîëüçóþò,
èëè âíåäðÿþò ÝÌÊ-ñèñòåìó.
•  2009 ãîäó, îòâå÷àÿ íà âîïðîñû àíàëî-
ãè÷íîãî îïðîñà, ïðîâåäåííîãî Medscape,
òðåòü ðåñïîíäåíòîâ ñîîáùèëè, ÷òî îíè íå
èìåþò ÝÌÊ-ñèñòåìû è çàêóïàòü èõ íå ïëàíè-
ðóþò. Îòðàæàÿ îãðîìíûé ñäâèã â ìåíòàëèòå-
òå, ïî ðåçóëüòàòàì îïðîñà 2012 ãîäà òîëüêî
6% ðåñïîíäåíòîâ çàÿâèëè î òîì, ÷òî îíè ïëà-
íèðóþò îñòàâàòüñÿ áåç ÝÌÊ-ñèñòåìû.
• Ïðè îöåíêå ÝÌÊ-ñèñòåì ïðèíèìàëîñü âî
âíèìàíèå ìíîæåñòâî ðàçëè÷íûõ ôàêòîðîâ, è
Ðèñ. 2. Óðîâåíü âíåäðåíèÿ ýëåêòðîííûõ ìåäèöèíñêèõ äîêóìåíòîâ â àìåðèêàíñêèõ
áîëüíèöàõ [17]

8. 62
ñðåäè íàèáîëåå âàæíûõ äëÿ âðà÷åé îêàçàëèñü
òàêèå õàðàêòåðèñòèêè ñèñòåì, êàê «ëåãêî
îñâàèâàåìàÿ» è «ïðîñòàÿ âî âíåäðåíèè».
• Ëèøü 5% îïðîøåííûõ ñ÷èòàþò, ÷òî ÝÌÊ-
ñèñòåìà íèêàê íå ïîâëèÿëà íà ïðàêòèêó èõ
ðàáîòû (êàê â ïîëîæèòåëüíóþ, òàê è â îòðèöà-
òåëüíóþ ñòîðîíó). Áîëüøå âðà÷åé, ÷åì ðàíü-
øå, ñ÷èòàþò, ÷òî ÝÌÊ-ñèñòåìà ïðèâåëà ñêî-
ðåå ê ñíèæåíèþ, à íå ê ïîâûøåíèþ ïðîèçâî-
äèòåëüíîñòè. «Ïðîèçâîäèòåëüíîñòü ÷àñòî
ïàäàåò èç-çà òîãî, ÷òî âðà÷è òåïåðü ñàìè
âåäóò ñâîå äåëîïðîèçâîäñòâî», ãîâîðèò Ñòåð-
ëèíã. «Âî ìíîãèõ ñëó÷àÿ âðà÷ íèêîãäà êàê ñëå-
äóåò íå èçó÷àë è íå îñâàèâàë ñèñòåìó è â
ðåçóëüòàòå âñå âðåìÿ áîðåòñÿ ñ íåé».
• Ïåðâûé ãîä âíåäðåíèÿ, êàê ïðàâèëî,
ñàìûé òðóäíûé, òàê êàê âðà÷ åùå òîëüêî ó÷èò-
ñÿ èíòåãðèðîâàòü ÝÌÊ-ñèñòåìó â ïðîöåññ
ïðèåìà ïàöèåíòîâ. Èç ÷èñëà âðà÷åé, ñîîá-
ùèâøèõ î íåãàòèâíîì âëèÿíèè ÝÌÊ-ñèñòåìû
íà èõ ïðàêòèêó, 82% ñ÷èòàþò, ÷òî ýòî ñòàëî
ñëåäñòâèåì ìåíüøåãî «çðèòåëüíîãî êîíòàêòà»
ñ ïàöèåíòàìè.
• Äëÿ 46% îïðîøåííûõ èíòåðîïåðàáåëü-
íîñòü ÿâëÿåòñÿ ñåðüåçíîé ïðîáëåìîé. «Åñëè
ãîâîðèòü îá èõ âíóòðåííåé äåÿòåëüíîñòè, òî
êîãäà ñèñòåìà óïðàâëåíèÿ ìåäèöèíñêîé ïðàê-
òèêîé (practice management system) ïðèîáðå-
òåíà ó îäíîãî ïîñòàâùèêà, à ÝÌÊ-ñèñòåìà —
îò äðóãîãî, òî îíè íå ñìîãóò êàê ñëåäóåò âçàè-
ìîäåéñòâîâàòü, èëè æå ìîæåò ñëó÷èòüñÿ, ÷òî
ïîðòàë äëÿ ïàöèåíòîâ ïëîõî âçàèìîäåéñòâóåò
ñ ÝÌÊ-ñèñòåìîì», ãîâîðèò ïî ýòîìó ïîâîäó
Ñòåðëèíã. «Âçàèìîäåéñòâèå ÝÌÊ-ñèñòåì,
èñïîëüçóåìûõ ðàçëè÷íûìè ìåäèöèíñêèìè
ïðàêòèêàìè, ïîêà ÷òî íàõîäèòñÿ â ïðîöåññå
ñòàíîâëåíèÿ. Ñêîðîñòíûå ìàãèñòðàëè ìåæäó
ïðàêòèêàìè åùå òîëüêî ïðîêëàäûâàþòñÿ, è â
äàííûé ìîìåíò ìû íå ìîæåì èìè âîñïîëüçî-
âàòüñÿ».
• Îñíîâíîé çàäà÷åé ñòàëî ïîäòâåðæäåíèå
«êîíñòðóêòèâíîãî èñïîëüçîâàíèÿ» ÝÌÊ-ñè-
ñòåì (îíî ÿâëÿåòñÿ ãëàâíûì óñëîâèåì ïîëó÷å-
íèÿ ñòèìóëèðóþùèõ âûïëàò — Í.Õ.). Òðè
÷åòâåðòè âðà÷åé ëèáî óæå ïðîøëè àòòåñòà-
öèþ íà êîíñòðóêòèâíîå èñïîëüçîâàíèå, ëèáî
ïëàíèðóþò ýòî ñäåëàòü.
Çàñëóæèâàåò âíèìàíèÿ è ðÿä äðóãèõ
ðåçóëüòàòîâ îïðîñà:
• Ñòîèìîñòü ÝÌÊ-ñèñòåìû â ðàñ÷åòå íà
îäíîãî âðà÷à êîëåáàëàñü â øèðîêèõ ïðåäå-
ëàõ, îäíàêî â áîëüøèíñòâå ñëó÷àåâ áûëà â
äèàïàçîíå îò 10 äî 35 òûñÿ÷ äîëëàðîâ.
Òèïè÷íàÿ ìåñÿ÷íàÿ îïëàòà âåá-ñèñòåìû îêà-
çàëàñü â ðàéîíå 400 äîëëàðîâ çà ðàáî÷åå
ìåñòî.
•  îäíîì ñëó÷àå èç òðåõ âðà÷è èñïîëüçó-
þò «òîíêèé» âåá-êëèåíò;
Ðèñ. 3. Êëþ÷åâûå èíäèêàòîðû ðûíêà ÝÌÊ

9. 63
• Ïÿòàÿ ÷àñòü âðà÷åé êðàéíå íåäîâîëüíà
ïîñòàâùèêàìè ÝÌÊ-ñèñòåì, à 10% ñîáèðàþò-
ñÿ ìåíÿòü ñâîþ ÝÌÊ-ñèñòåìó.
• 30% âðà÷åé ñ÷èòàþò, ÷òî ÝÌÊ-ñèñòåìà
íåãàòèâíî ïîâëèÿëà íà âçàèìîîòíîøåíèÿ ñ
ïàöèåíòàìè, â òî âðåìÿ êàê 38% âèäÿò ïîëî-
æèòåëüíîå âëèÿíèå.
• Áåñïîêîéñòâî ïî ïîâîäó çàùèòû ïåðñî-
íàëüíûõ äàííûõ âûðàçèëà ÷åòâåðòü îïðîøåí-
íûõ.
Äîñòèæåíèÿ è ïðîáëåìû
Áåçóñëîâíî, àìåðèêàíñêàÿ ìåäèöèíà äîáè-
ëàñü ñåðüåçíûõ óñïåõîâ âî âíåäðåíèè ñîâðå-
ìåííûõ èíôîðìàöèîííûõ òåõíîëîãèé â ìåäèöè-
íå. Èñïîëüçîâàíèå ìåäèöèíñêèõ èíôîðìàöèîí-
íûõ ñèñòåì è ÝÌÊ-ñèñòåì ñòàíîâèòñÿ íîðìîé,
îáÿçàòåëüíûì óñëîâèåì ðàáîòû â îòðàñëè. ×òî
êàñàåòñÿ âîïðîñîâ ïðîèçâîäèòåëüíîñòè òðóäà,
ýêîíîìè÷åñêîé ýôôåêòèâíîñòè è ïîâûøåíèÿ
êà÷åñòâà ìåäèöèíñêèõ óñëóã, òî ïîêà ñêîðåå
ñäåëàí áîëüøîé çàäåë íà áóäóùåå, ÷åì ïîëó-
÷åíà ðåàëüíàÿ îòäà÷à.  íàñòîÿùåå âðåìÿ
äàëüíåéøåìó âíåäðåíèþ ÈÒ â ìåäèöèíå íà÷è-
íàþò ìåøàòü ñëîæíàÿ ýêîíîìè÷åñêàÿ ñèòóàöèÿ
â ñòðàíå, ïîëèòè÷åñêàÿ áîðüáà âåäóùèõ ïàð-
òèé, â ôîêóñå êîòîðîé îêàçàëèñü âîïðîñû
ìîäåðíèçàöèè íàöèîíàëüíîãî çäðàâîîõðàíå-
íèÿ, à òàêæå òîò ôàêò, ÷òî, áóäó÷è îäíèì èç
ïèîíåðîâ âíåäðåíèÿ èíôîðìàöèîííûõ ñèñòåì
â ìåäèöèíå, ÑØÀ íàêîïèëè áîëüøîé «áàë-
ëàñò» â âèäå ìîðàëüíî óñòàðåâøèõ ñèñòåì
òàêîãî ðîäà, äëÿ èçáàâëåíèÿ îò êîòîðîãî
òàêæå ïîòðåáóþòñÿ êðóïíûå èíâåñòèöèè.
Äàæå ñðåäè òåõ âðà÷åé, ÷òî îñâîèëè ýëåê-
òðîííûå äîêóìåíòû, ìíîãèå ñòîëêíóëèñü ñ
îãðîìíûì êàìíåì ïðåòêíîâåíèÿ â âèäå ïðî-
áëåìû èíòåðîïåðàáåëüíîñòè (ñîâìåñòèìîñòè).
Äîêóìåíòû, ñ êîòîðûìè îíè ðàáîòàþò â ñâîèõ
îôèñàõ, ìîãóò íå âîñïðèíèìàòüñÿ èíûì ïðî-
ãðàììíûì îáåñïå÷åíèåì, ïðèìåíÿåìûì â
áîëüíèöàõ. Ïî äàííûì îïðîñà, íåäàâíî ïðî-
âåäåííîãî Öåíòðîì ñîãëàñîâàííîé äâóõïàð-
òèéíîé ïîëèòèêè (Bipartisan Policy Center),
70% âðà÷åé íàçâàëè îòñóòñòâèå èíòåðîïåðà-
áåëüíîñòè â êà÷åñòâå ïðè÷èíû íåóäîâëåòâî-
ðåííîñòè ýëåêòðîííûìè äîêóìåíòàìè [19].
Ïî ìíåíèþ ñïåöèàëèñòîâ êîðïîðàöèè
RAND, «â ðåçóëüòàòå íûíåøíåå ïîêîëåíèå
ýëåêòðîííûõ ìåäèöèíñêèõ äîêóìåíòîâ ôóíêöè-
îíèðóåò íå ñòîëüêî êàê «áàíêîâñêèå êàðòû»,
ïîçâîëÿþùèå ïàöèåíòó èëè ïîñòàâùèêó ìåäè-
öèíñêèõ óñëóã ïîëó÷àòü äîñòóï ê íåîáõîäèìîé
ìåäèöèíñêîé èíôîðìàöèè â ëþáîì ìåñòå â
ëþáîå âðåìÿ, à ñêîðåå êàê «êàðòû ÷àñòî
ëåòàþùèõ» (frequent flier cards), ïðåäíàçíà÷åí-
íûå äëÿ îáåñïå÷åíèÿ ëîÿëüíîñòè ê êîíêðåòíîé
ñèñòåìå îêàçàíèÿ ìåäèöèíñêèõ óñëóã» [20].
 îñíîâàííîé íà ðåçóëüòàòàõ äðóãîãî,
íåçàâèñèìî ïðîâåäåííîãî èññëåäîâàíèÿ,
ñòàòüå «Ïðåäîñòàâëåíèå ðàáîòàþùèì â îôè-
ñàõ âðà÷àì ýëåêòðîííîãî äîñòóïà ê ðåçóëüòà-
òàì ðàíåå ïðîâåäåííûõ îáñëåäîâàíèé è
ëàáîðàòîðíûõ àíàëèçîâ íå ñíèçèëî êîëè÷åñò-
âî íàïðàâëåíèé íà èññëåäîâàíèÿ è àíàëèçû»
[21], ïîäíèìàåòñÿ âîïðîñ î òîì, ïî÷åìó
ïîñëå âíåäðåíèÿ ýëåêòðîííûõ äîêóìåíòîâ
ðàñõîäû íà ñàìîì äåëå âîçðîñëè. Â óñëîâèÿõ,
êîãäà, íàïðèìåð, íàïðàâëåíèå íà àíàëèçû
îôîðìëÿåòñÿ îäíèì ùåë÷êîì ìûøè, ìíîãèå
îæèäàþò, ÷òî áëàãîäàðÿ òåõíîëîãèÿì îáúåìû
îêàçûâàåìîé ìåäèöèíñêîé ïîìîùè â êîíå÷-
íîì ñ÷åòå äîëæíû áûòü áîëüøå, ÷åì â íåýëåê-
òðîííîé ñðåäå.
Åñòü, îäíàêî, è òå, êòî ñ÷èòàþò ýêîíîìèþ
âïîëíå äîñòèæèìîé. Ïî îöåíêàì Äåïàðòàìåí-
òà ïî äåëàì âåòåðàíîâ (Department of Veteran
Affairs), îí çà øåñòü ëåò ñýêîíîìèë áîëåå
3 ìèëëèàðäîâ äîëëàðîâ, ñîêðàòèâ íåíóæíûå
ðàñõîäû íà çäðàâîîõðàíåíèå ïîñëå òîãî, êàê
â ìàñøòàáàõ âåäîìñòâà áûëè âíåäðåíû ýëåê-
òðîííûå ìåäèöèíñêèå äîêóìåíòû [22].
Ïðîáëåìà îáåñïå÷åíèÿ èíôîð-
ìàöèîííîé áåçîïàñíîñòè
Êàê â ïðîôåññèîíàëüíîé ëèòåðàòóðå, òàê è
â ÑÌÈ ìíîãî ãîâîðèòñÿ î ïðîáëåìàõ èíôîð-
ìàöèîííîé áåçîïàñíîñòè â çäðàâîîõðàíåíèè.
Ýòî òå æå ïðîáëåìû, ñ êîòîðûìè ïðèõîäèòñÿ
ñòàëêèâàòüñÿ ðàçðàáîò÷èêàì ëþáûõ äðóãèõ

10. 64
èíôîðìàöèîííûõ ñèñòåì, îäíàêî ïîñëåäñòâèÿ
èíöèäåíòîâ áåçîïàñíîñòè âî ìíîãèõ ñëó÷àÿõ
áîëåå òÿæåëûå, ÷åì â áîëüøèíñòâå äðóãèõ
îòðàñëåé.
Êàê ñîîáùèëà ãàçåòà «Âàøèíãòîí ïîñò» ïî
èòîãàì ãîäè÷íîãî èññëåäîâàíèÿ òî, ÷òî çäðà-
âîîõðàíåíèå, î÷åðòÿ ãîëîâó, áðîñèëîñü îñâàè-
âàòü èíôîðìàöèîííûå òåõíîëîãèè è áåñïðî-
âîäíûå ñåðâèñû, çíà÷èòåëüíî óâåëè÷èëî åãî
óÿçâèìîñòü ê õàêåðñêèì àòàêàì, îò÷àñòè èç-çà
òîãî, ÷òî îòðàñëü íå ñïåøèò ïðèíèìàòü ìåðû
â îòíîøåíèè èçâåñòíûõ ðèñêîâ [23].
Òåõíè÷åñêèé äèðåêòîð Èíñòèòóòà èíôîðìà-
öèîííîé áåçîïàñíîñòè ïðè Óíèâåðñèòåòå
Äæîíñà Õîïêèíñà Àâè Ðàáèí (Avi Rubin) â
èíòåðâüþ ãàçåòå «Âàøèíãòîí ïîñò» ñêàçàë: «ß
íèêîãäà íå âèäåë îòðàñëè ñ áîëåå çèÿþùèìè
äûðàìè â ñèñòåìå áåçîïàñíîñòè. Åñëè áû
íàøà ôèíàíñîâàÿ îòðàñëü îòíîñèëàñü ê
âîïðîñàì áåçîïàñíîñòè òàê æå, êàê çäðàâî-
îõðàíåíèå, òî ÿ áû õðàíèë ñâîè äåíüãè â
ìàòðàöå ìîåé êðîâàòè» [24].
Ïî äàííûì ãàçåòû, Ðàáèí îáíàðóæèë, ÷òî
ÈÒ-ñïåöèàëèñòû ìåäèöèíñêèõ ó÷ðåæäåíèé
íåðåäêî íå êîððåêòèðóþò èìåþùåå íåäîñòàò-
êè ïðîãðàììíîå îáåñïå÷åíèå, à ìåäèöèíñêèå
ðàáîòíèêè ðåãóëÿðíî ïðåíåáðåãàþò ìåðàìè
áåçîïàñíîñòè.
Ìíîãèå èçâåñòíûå êðóïíûå óòå÷êè ìåäèöèí-
ñêèõ äàííûõ ñòàëè ðåçóëüòàòîì äåéñòâèé õàêå-
ðîâ, èùóùèõ äîñòóï ê ïåðñîíàëüíûì äàííûì
ïàöèåíòîâ, êîòîðûå çàòåì èñïîëüçóþòñÿ äëÿ
ìîøåííè÷åñòâ òèïà «êðàæè ëè÷íîñòè».  öåëîì
áîëüøèíñòâî èíöèäåíòîâ áûëî ñâÿçàíî ñ ïîòå-
ðåé íîóòáóêîâ è äðóãèõ ìîáèëüíûõ óñòðîéñòâ.
Êàê îòìåòèëà «Âàøèíãòîí ïîñò», òàêæå
ÿâëÿþòñÿ óÿçâèìûìè äëÿ õàêåðîâ òàêèå ìåäè-
öèíñêèå óñòðîéñòâà, êàê ñåðäå÷íûå äåôè-
áðèëëÿòîðû è èíñóëèíîâûå ïîìïû, è ëåòîì
2012 ãîäà íà ýòî óêàçûâàëà â ñâîåì îò÷åòå
Ñ÷åòíàÿ ïàëàòà ÑØÀ (General Accountability
Office, GAO). Ñ÷åòíàÿ ïàëàòà ðåêîìåíäîâàëà
Óïðàâëåíèþ ïî êîíòðîëþ çà êà÷åñòâîì ïèùå-
âûõ ïðîäóêòîâ è ìåäèêàìåíòîâ ðàñøèðèòü
ñôåðó ñâîåé äåÿòåëüíîñòè â ïëàíå êîíòðîëÿ
çà ìåäèöèíñêèìè óñòðîéñòâàìè è îáðàòèòü
âíèìàíèå íà êèáåðóãðîçû [25].
Ýêñïåðòîâ òàêæå áåñïîêîèò òî, ÷òî íåäî-
îöåíèâàþòñÿ ðèñêè äëÿ çäîðîâüÿ ïàöèåíòîâ,
ñâÿçàííûå ñî ñáîÿìè â ðàáîòå ýëåêòðîííûõ
ìåäèöèíñêèõ ñèñòåì. Ïî ìíåíèþ Ñêîòà Ñèëü-
âåðñòàéíà (Scot Silverstein) èç Óíèâåðñèòåòà
Äðåêñåëü (Drexel University), âåäóùåãî êðèòèêà
èäåè áûñòðîãî ïåðåõîäà íà êîìïüþòåðèçèðî-
âàííûå ìåäèöèíñêèå êàðòû, óòâåðæäåíèå î
òîì, ÷òî ÝÌÊ-ñèñòåìû ïðåäîòâðàùàþò áîëü-
øå âðà÷åáíûõ îøèáîê, ÷åì ñàìè ïðîâîöèðó-
þò, ïîêà íå äîêàçàíî [26].
Ñèëüâåðñòàéí ïðèâîäèò â ïðèìåð èçâåñò-
íûå ôàêòû, òàêèå êàê ñëó÷àé â êëèíèêå íà Ðîä
Àéëåíä (Rhode Island). Â 2011 ãîäó áûëà
ðàñêðûòà èíôîðìàöèÿ î òîì, ÷òî ïðîãðàì-
ìíîå îáåñïå÷åíèå, èñïîëüçóåìîå áîëüíè÷íîé
ãðóïïîé Lifespan, áûëî äåôåêòíûì. Â ðåçóëü-
òàòå ñáîÿ îíî ðàñïå÷àòàëî ðàñïîðÿæåíèÿ î
âûäà÷å ïàöèåíòàì òàáëåòîê êîðîòêîãî ñðîêà
äåéñòâèÿ ñ íèçêèì ñîäåðæàíèåì àêòèâíûõ
âåùåñòâ, â òî âðåìÿ êàê îíè äîëæíû áûëè
ïîëó÷àòü áîëåå ñèëüíûå ëåêàðñòâà äëèòåëüíî-
ãî äåéñòâèÿ.
Ñðåäè èçâåñòíûõ èíöèäåíòîâ â ìåäèöèíñêèõ
ó÷ðåæäåíèÿõ ÑØÀ — îøèáêà ïðè ââîäå äàí-
íûõ, êîòîðàÿ ïðèâåëà ê ñìåðòè â 2010 ãîäó
ðåáåíêà â áîëüíèöå Advocate Lutheran Gen-
eral Hospital â øòàòå Èëëèíîéñ; è ïðîáëåìà,
èìåâøàÿ ìåñòî â êîìïüþòåðíîé ñèñòåìå êðóï-
íåéøåãî ïîñòàâùèêà ìåäèöèíñêèõ óñëóã íà
àìåðèêàíñêîì Ñðåäíåì Çàïàäå — ãðóïïû Tri-
nity Health System, êîãäà óêàçàíèÿ âðà÷à
çàíîñèëèñü â êàðòû ñîâñåì äðóãèõ ïàöèåíòîâ.
Ïî ìíåíèþ Ñèëüâåðñòàéíà. ñëåäñòâèåì
ñïåøêè ñ âíåäðåíèåì ÝÌÊ ñòàëî ïîÿâëåíèå
ïëîõî ñïðîåêòèðîâàííûõ ïðîäóêòîâ, êîòîðûå
ñêîðåå ìîãóò çàïóòàòü âðà÷åé, ÷åì ïîìî÷ü èì.
ÝÌÊ-ñèñòåìû ñëåäóåò òùàòåëüíî òåñòèðîâàòü
ïîä êîíòðîëåì ïðàâèòåëüñòâà, ïðåæäå ÷åì
ïðèìåíÿòü â ñèòóàöèÿõ, êîãäà ðåøàåòñÿ
âîïðîñ æèçíè èëè ñìåðòè ïàöèåíòà, — òàê æå,
êàê ïîñòóïàþò, íàïðèìåð, ñ ìåäèöèíñêèì
îáîðóäîâàíèåì èëè ñàìîëåòàìè [27].

11. 65
ËÈÒÅÐÀÒÓÐÀ
1. Â Ðîññèè ýëåêòðîííûå ìåäèöèíñêèå êàðòû ïàöèåíòîâ äîëæíû áûòü ââåäåíû ê êîíöó ãîäà —
ìèíèñòð çäðàâîîõðàíåíèÿ//FINMARKET.RU. — 16 àïðåëÿ 2013 ãîäà, http://www.finmar-
ket.ru/z/nws/news.asp?id=3306993&rid=1.
2. «Interview with Lawrence Weed: The Father of the Problem-Oriented Medical Record Looks
Ahead», Perm J. 2009 Summer; 13(3): 84-89, http://www.ncbi.nlm.nih.gov/pmc/artic-
les/PMC2911807/.
3. Ogg Tom Electronic Medical Records: It's Back to the Future//Akron Children's Hospital, Feb-
ruary 20, 2012. — http://inside.akronchildrens.org/2012/02/20/electronic-medical-records-its-
back-to-the-future/.
4. Gungor Fig The History of Electronic Health Records Software», May 10, 2012. — http://www.on-
esourcedoc.com/blog/bid/82838/The-History-of-Electronic-Health-Records-Software.
5. Weed Lawrence Medical Records that Guide and Teach//New England Journal of medicine,
278:593–600, 652–67 (March 14, 21), 1968. — http://imed.stanford.edu/curriculum/ses-
sion17/content/NEJM%20-%20Medical%20record%20that%20guide%20and%20teach%20%
28Weed%20-%201968%29.pdf.
6. «Interview with Lawrence Weed: The Father of the Problem-Oriented Medical Record Looks
Ahead», Perm J. 2009 Summer; 13(3): 84-89, http://www.ncbi.nlm.nih.gov/pmc/articles/
/PMC2911807/.
7. «Interview with Lawrence Weed: The Father of the Problem-Oriented Medical Record Looks
Ahead», Perm J. 2009 Summer; 13(3): 84-89, http://www.ncbi.nlm.nih.gov/pmc/artic-
les/PMC2911807/; Gungor Fig «The History of Electronic Health Records Software», May 10,
2012, http://www.onesourcedoc.com/blog/bid/82838/The-History-of-Electronic-Health-Records-
Software.
8. VistA History // http://worldvista.org/AboutVistA/VistA_History.
9. Gungor Fig The History of Electronic Health Records Software, May 10, 2012, http://www.on-
esourcedoc.com/blog/bid/82838/The-History-of-Electronic-Health-Records-Software.
10. Hsiao Chun-Ju, Hing Esther, Socey Thomas C. and Cai Bill Electronic Medical Record/Electro-
nic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010
State Estimates», National Center for Health Statistics, December 2010, http://www.cdc.gov/
/nchs/data/hestat/emr_ehr_09/emr_ehr_09.pdf.
Çàêëþ÷åíèå
Àìåðèêàíñêèé îïûò âíåäðåíèÿ ýëåêòðîí-
íûõ ìåäèöèíñêèõ êàðò íàãëÿäíî ïîêàçûâàåò,
íàñêîëüêî ýòî íåïðîñòàÿ çàäà÷à. Äàæå òàêîé
áîãàòîé ñòðàíå è ê òîìó æå ëèäåðó â ñôåðå
ñîâðåìåííûõ òåõíîëîãèé, êàê ÑØÀ, çà ñîðîê
ëåò óñèëèé ïî ðàñïðîñòðàíåíèþ ÝÌÊ ïîëíî-
ñòüþ ïåðåâåñòè ó÷ðåæäåíèÿ çäðàâîîõðàíåíèÿ
íà èñïîëüçîâàíèå ýëåêòðîííûõ äîêóìåíòîâ
ïîêà íå óäàëîñü. Äâèæåíèå âïåðåä âî ìíîãîì
ñâÿçàíî ñ óìåëûì ïðèìåíåíèåì êàê ïîëîæè-
òåëüíûõ, òàê è îòðèöàòåëüíûõ ñòèìóëîâ.
Îáðàùàåò íà ñåáÿ âíèìàíèå òî, ÷òî â
ÑØÀ òùàòåëüíî èçó÷àåòñÿ îïûò âíåäðåíèÿ
ýëåêòðîííûõ ìåäèöèíñêèõ êàðò, îòñëåæèâàåò-
ñÿ îòíîøåíèå ê íèì ìåäèöèíñêèõ ðàáîòíè-
êîâ; ïðè ýòîì îñîáîå âíèìàíèå óäåëÿåòñÿ
ñóùåñòâóþùèì è íàìå÷àþùèìñÿ ïðîáëåìàì.
Êàê ìíå êàæåòñÿ, ýòîò îïûò íàì áûëî áû
ïîëåçíî âçÿòü «íà âîîðóæåíèå» ñ òåì, ÷òîá
èìåòü âîçìîæíîñòü âîâðåìÿ âíîñèòü èçìåíå-
íèÿ â õîä ðåàëèçàöèè îòå÷åñòâåííûõ ïðî-
ãðàìì â ýòîé îáëàñòè.

12. 66
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ce», Medscape, October 06, 2009, http://www.medscape.com/viewarticle/709856.
12. Hsiao Chun-Ju, Hing Esther, Socey Thomas C. and Cai Bill Electronic Medical Record/Electro-
nic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010
State Estimates, National Center for Health Statistics, December 2010, http://www.cdc.gov/
/nchs/data/hestat/emr_ehr_09/emr_ehr_09.pdf.
13. Physician Adoption of Electronic Health Record Systems: United States, 2011//NCHS Data
Brief, No. 98, July 2012, http://www.cdc.gov/nchs/data/databriefs/db98.pdf.
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http://www.washingtonpost.com/blogs/wonkblog/wp/2013/01/11/why-electronic-health-records-failed/.
15. Kellerman Arthur, Jones Spencer What It Will Take To Achieve The As-Yet-Unfulfilled Promises
Of Health Information Technology//Health Aff. — January 2013. — V. 32. — ¹ 1. — P. 63–68,
http://content.healthaffairs.org/content/32/1/63.full.
16. Kellerman Arthur, Jones Spencer What It Will Take To Achieve The As-Yet-Unfulfilled Promises
Of Health Information Technology//Health Aff. — January 2013. — V. 32. — ¹ 1. — P. 63–68,
http://content.healthaffairs.org/content/32/1/63.full.
17. Kliff Sarah Why electronic health records failed//Wonkblog, January 11, 2013,
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/01/11/why-electronic-health-records-failed/.
18. EHR Report 2012: Physicians Rank Top EHRs//Medscape, August 23, 2012, http://www.med-
scape.com/features/slideshow/EHR2012.
19. Bipartisan Policy Center Calls for Collaborative Action to Accelerate Electronic Information
Sharing to Improve Quality and Reduce Costs in Health Care//Bipartisan Policy Center, Oct. 4, 2012;
P. 6; http://bipartisanpolicy.org/news/press-releases/2012/10/bipartisan-policy-center-calls-col-
laborative-action-accelerate-electroni.
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http://www.washingtonpost.com/blogs/wonkblog/wp/2013/01/11/why-electronic-health-records-failed/.
21. McCormick D., Bor D.H., Woolhandler S., Himmelstein D.U. Giving Office-Based Physicians
Electronic Access To Patients' Prior Imaging And Lab Results Did Not Deter Ordering Of Tests//
Health Affairs. — March 2012. — V. 31. — ¹ 3. — P.488–496, http://content.healthaffairs.org/
content/31/3/488.abstract/.
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http://www.washingtonpost.com/blogs/wonkblog/wp/2013/01/11/why-electronic-health-records-failed/.
23. ñì.: Health-care sector vulnerable to hackers, researchers say // Washington Post?
25/12/2012, http://www.washingtonpost.com/investigations/health-care-sector-vulnerable-to-
hackers-researchers-say/2012/12/25/72933598-3e50-11e2-ae43-cf491b837f7b_story_1.html.
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