How does national power promote the improvement of the application level of electronic medical record

How does national power promote the improvement of the application level of electronic medical record | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article How does national power promote the improvement of the application level of electronic medical record Lang Shu, Dan Fan, Xinyue Wang, Jiangrong Luo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8609608/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Like many low- and middle-income countries, the development of electronic medical record (EMR) systems in China was slow due to the lack of funds. It was not until 2019, when the government incorporated the evaluation of EMR systerms into the assessment indicators for large public hospitals that the application of EMR systems achieved a qualitative improvement. Our hospital was one of the pilot hospitals for this reform. Methods The National Health Commission of China has divided the application level of EMR systems into 9 levels. Levels 1 to 3 are the beginner level, with the goal being the electronic collection of medical data and the internal data sharing within departments; levels 4 to 5 are the intermediate level, with the goal being the system integration of the hospital and unified data management; levels 6 to 8 are the advanced level, with the goal being the sharing of regional medical information across cities, as well as the regional medical safety and quality control. Results From 2011 to 2017, our hospital promoted the development of the EMR system from level 0 to 4 through internal demands. After 2019, the national power prompted our hospital to raise the EMR system to level 5 in 2020 and level 6 in 2023. In 2012, 2020 and 2023, the average level of EMR systems in hospitals participating in the "National Examination" across the country was 1, 2.43 and 3.24; The number of hospitals with EMR system ratings at and above level 5 was 5–7,176 and 395. Conclusions In countries that cannot provide sufficient funds for the reform of medical informatization, a system for rating EMR and hospital assessment similar to the one in this study can be established. electronic medical record medical digital reform low- and middle-income countries Figures Figure 1 Figure 2 1. Introduction The use of paper-based patient record systems has numerous drawbacks, such as being prone to loss, duplication, theft, fire damage, and being restricted for research purposes. Now we are facing a new drawback, namely that during the process of handling the records, the novel coronavirus (SARS-CoV-2) and other infectious diseases may be transmitted. In the early 1960s, the United States was the first to apply computers to hospital management and established several computerized hospital management systems. Nowadays, the EMR system is one of the main systems in hospital management information systems, and its application has become quite widespread in developed countries. Research on computerized hospital management systems in China began in the late 1970s [1]. For instance, from 1979 to 1986, the Heilongjiang Provincial Hospital established a multi-functional computerized hospital management system, which covered aspects such as medical record management, personnel file management, treatment quality assessment, medical statistics, pharmacy management and medical equipment management [2]. Like many developing countries, the development of EMR systems in China has been slow, due to the lack of financial support. China has a vast territory and a large population, and its economic output ranks among the top in the world. However, the per capita gross domestic product (GDP) is low and the country's investment in healthcare is insufficient. The National Bureau of Statistics of China reported that as of 2017, the total population of China was approximately 1.4 billion, accounting for about 20% of the global population. On May 19, 2020, the World Bank released the per capita GDP calculated based on the latest (2017 round) International Comparison Program. The per capita GDP of China was $ 14,150, which was equivalent to 23.6% of the per capita GDP of the United States in the same year. Chinese public health investment accounts for less than 8% of the GDP [3]. In order to encourage public hospitals to allocate more of their limited funds to the development of EMR systems, the National Health Commission of China included the rating of the application level of EMR systems in the performance assessment of large public hospitals in 2019. Sichuan Provincial People's Hospital (our hospital) is one of the pilot hospitals for this assessment. Sichuan Province covers an area of approximately 486,000 square kilometers and is the fifth largest province in China. As of 2024, its permanent resident population is 83.64 million. Our hospital is one of the large hospitals in Sichuan Province established in 1941. As of 2024, it has 4,500 beds, over 7,000 staff members, about 1,700 doctors, approximately 1.5 million outpatient visits per year, about 47,000 inpatient visits per year, and 25,000 surgeries per year. To serve such a large number of patients and staff, our hospital must enhance the application level of the EMR system to enhance service efficiency, ensure medical safety and provide decision-making data. This study reports on how our hospital has improved the application level of the EMR system from 2011 to 2024 (level 0 to 6), with a focus on analyzing how the application level of the EMR system was enhanced after our hospital participated in the performance assessment of large public hospitals by the National Health Commission in 2019 (level 5 to 6). This research provides a demonstration for developing countries lacking financial support on how to utilize national power to promote medical informatization. Statement of Significance Problem or Issue: Like many low- and middle-income countries, the development of electronic medical record (EMR) systems in China was slow due to the lack of funds. It was not until 2019, when the government incorporated the evaluation of EMR systems into the assessment indicators for large public hospitals that the application of EMR systems achieved a qualitative improvement. What is Already Known : The United States has a clear and mature grading evaluation system for EMR systems. Its core logic is "using economic levers to promote the standardization of clinical processes and information interconnection". What this Paper Adds : Providing an administrative review-driven model in China. Who would benefit from the new knowledge in this paper : In countries that cannot provide sufficient funds for the reform of medical informatization, a system for rating EMR and hospital assessment similar to the one in this study can be established. 2. Methods 2.1 The definition of the "National Examination" The National Health Commission of China classifies China's public hospitals into three levels. The tertiary hospitals are the highest level of hospitals, usually being large hospitals in a region. Our hospital is a tertiary hospital. "The Performance Evaluation of China's Tertiary Public Hospitals" is abbreviated as "National Examination" by Chinese hospitals. It was implemented since 2019 and is the most important national hospital assessment for large public hospitals in China. It assesses all tertiary hospitals in China, with approximately 2,000 hospitals (the number changes slightly each year). It is organized and implemented by the National Health Commission and is an important mechanism for evaluating core indicators such as the hospital's comprehensive management level, medical service quality, and operational efficiency. The assessment results directly affect the country's rating of hospitals, policy support, and resource allocation, aiming to promote the high-quality development of public hospitals. The national classification of the application level of EMR systems in hospitals has been included as the sole information technology indicator for the "National Examination" [4]. EMR, as the core and foundation of smart hospitals, are the priority area for hospital infrastructure construction. 2.2 Grading evaluation standards for the application level of EMR systems The “Grading evaluation standards for the application level of EMR systems” (The rating criteria were released in 2011, and were incorporated into the "National Examination" scoring system in 2019) [5] is divided into 9 levels ranging from 0 to 8, involving 10 job roles and 39 evaluation items ( Fig. 1 ) . Levels 1 to 3 are the beginner level, with the goal being the electronic collection of medical data and the internal data sharing within departments; levels 4 to 5 are the intermediate level, with the goal being the system integration of the hospital and unified data management; levels 6 to 8 are the advanced level, with the goal being the sharing of regional medical information across cities, as well as the regional medical safety and quality control. The selection of 39 evaluation items takes into account aspects such as medical, medical technology, medical insurance, the foundation of EMR, and information utilization, and is examined from three dimensions: the functions of the system, the effective application scope of the system, and data quality. According to the requirements corresponding to the EMR application level of 0 to 8 grades, the functional requirements and evaluation contents for each evaluation item were determined. The total score of the evaluation is the sum of the scores of each item during the local evaluation, and it is a quantitative indicator reflecting the overall application situation of EMR in medical institutions. The total score should not be lower than the minimum total score standard required for that level. For example, if the EMR system of a medical institution is to be evaluated at the 3rd level, the total score must not be less than 85 points. Table 1 shows the general requirements for grading evaluation of the application level of EMR systems. Table 1 General requirements for grading evaluation of the application level of EMR systems Level Basic items Optional items Minimum total score (points) 8 22 4/17 220 7 22 4/17 190 6 21 15/18 170 5 20 16/19 140 4 16 10/23 110 3 14 12/25 85 2 10 15/27 55 1 5 20/32 28 0 N/A N/A N/A Note: The basic items refer to the items that must be met at that level, while the optional items refer to the items that can be selectively met at that level. Among the optional items, "4/17" indicates that at least 4 out of the 17 optional items need to be met. N/A indicates that there are no requirements. Table 2 shows an example of the specific scoring requirements of a basic item (Ward order processing) based on a job role (Physician in ward). Due to the large amount of text in the specific scoring requirements of all basic items based on all job roles, they can be obtained from the official website of the National Health Commission at https://www.nhc.gov.cn Table 2 An example of the specific scoring requirements of a basic item(Ward order processing) based on a job role (Physician in ward) Evaluation content Score (points) The physician issues medical orders manually. 0 (1) Issue medical orders on the computer and record them locally. (2) Exchange data with other computers via disks, files. 1 The medical orders are transmitted via the network between the different procedures and then delivered to the nurses in the ward. 2 (1) The medical orders are available simultaneously for nurses, pharmacists and other staff to use via the network. (2) It is possible to obtain the availability of drugs in the pharmacy department. (3) There is a unified medical order item dictionary for the entire hospital. (4) When the medical orders are issued, it is possible to obtain the drug formulation, dosage, or at least one type of item from the examination and inspection list that is verified and prompted according to the rules of the dictionary. 3 (1) The information such as drugs, tests and examinations in the medical orders can be transmitted to the corresponding executing departments. (2) When the medical orders are issued, the related items can obtain drug knowledge,such as having the function of querying drug instructions. 4 (1) Medical orders can be uniformly managed and displayed in the hospital. (2) There is a control mechanism for the authority of physicians to issue drug treatment orders, and it supports the classification of antibacterial drugs usage management. (3) Based on the diagnosis, the situation of infectious diseases can be determined, and it can be reported to the medical administration department through the system. 5 (1) There is a reporting and handling function for adverse reactions of the prescribed drugs for medical treatment orders. (2) The prescribing physician can receive the evaluation results of their own prescriptions. (3) When issuing medical orders, it is possible to conduct automatic checks by referring to at least 4 pieces of content from the knowledge base such as drugs, examinations, tests, drug allergies, diagnoses, gender, etc., and provide prompts. (4) It is possible to monitor the status of each link of the medical order execution in real time. (5) It supports electronic application and process tracking for in-hospital consultations. 6 (1) When giving medical orders, it can automatically compare the execution and variation situations based on the clinical pathway (guidelines) requirements and the patient's specific data, prompt the input of the variation reasons and record them. (2) Based on the test results, medication use, etc., it automatically issues early warnings and provides prompts for infectious diseases, hospital infection outbreaks, etc., and supports the supplementation of information and reporting to the medical administration department for confirmed infectious diseases, hospital infection outbreaks, etc. (3) When giving medical orders, all medical records within the institution and relevant medical records from external medical institutions of the patient can be queried. (4) Automatically conduct a verification of medical orders based on the past diagnosis and treatment situations within and outside the medical institution, and provide prompts. (5) Based on the medical orders, execution status and knowledge base, automatically determine adverse event situations and provide prompts. (6) Support physicians to browse medical order records outside the hospital. 7 It can share patients' medical and health information and enable centralized display, including medical information within and outside the institution, health records, physical examination results, follow-up information, patients' self-collected health records (such as health records, wearable device data), etc. 8 Overall, Fig. 1 , Table 1 and Table 2 provide detailed and clear visual representations of the differences between various levels. 2.3 How can countries and hospitals achieve the predetermined level of EMR? The country has established the framework (grading evaluation standards) to promote hospitals integrate and upgrade their internal systems. Each hospital uploads system data to the national data platform. Subsequently, The National Health Commission organizes expert groups to conduct online and on-site evaluations of the hospitals, and the evaluation results are made public to allow patients to understand the hospital's level. The results affect the hospital's reputation. The higher the level, the more attractive it is to patients, and it also attracts more social donations and national grants for projects such as hospital building construction and medical equipment procurement. Taking our hospital as an example, here are the steps for upgrading our EMR from level 5 to 6. 2.3.1 Step 1: Preparatory work Through literature review and on-site investigation methods, we aimed to understand the functions of the mainstream EMR systems in China and the feedback on their usage. The investigation covered aspects such as the basic situation of the hospital, the number of outpatient and inpatient visits, the usage of rational drug use software, the level of application of electronic medical records, and usage suggestions. 2.3.2 Step 2: Establish the project implementation team Form a project implementation team consisting of the hospital president, information center engineers, software manufacturer engineers, doctors, nurses, and technicians. The hospital president is responsible for controlling the entire project implementation process; the information center engineers are responsible for the overall construction of software and hardware, system operation and maintenance, and information security; the software manufacturer engineers are responsible for the development and implementation of each module of the software, as well as the design of interface technical solutions; doctors, nurses, and technicians are responsible for coordinating all parties and communicating with engineers to design appropriate software processes, etc. 2.3.3 Step 3: Project implementation (Taking rational drug use in outpatient departments as an example) The clinical pharmacists and information center engineers jointly compare the application level standard of the EMR system at level 6, sort out all the functional points related to rational drug use in the rating standards, establish the outpatient rational drug use process and the closed-loop system for prescription data circulation. From the perspectives of patients, physicians, and drugs, analyze the key points in the three steps before, during, and after the generation of prescriptions, clearly define the functions of each module that need to be constructed, and ensure the informatization and traceability of each link in outpatient drug use. 2.3.4 Step 4:Closed-loop system construction (Taking rational drug use in outpatient departments as an example) (1) Before prescription generation: A unified rational drug use knowledge base for the entire hospital was established. When clinical physicians issue prescriptions, the system conducts real-time verification. Based on the patient's diagnosis, gender, history of drug allergies, and previous test and examination results, according to the warning information types set in the "system settings", the system will prompt for any unreasonable issues in the prescription. The system supports merging the prescriptions of outpatient patients for review on the same day, and when the outpatient physician issues a prescription, the system can monitor the prescriptions that the same patient has already taken in the past. The system supports pharmacists viewing real-time prescriptions and also supports clinical directors and physicians in viewing the problem prescriptions in their departments and personally. (2) Prescription generation: After the prescription is saved, it will enter the rational drug use review module for rationality review before drug dispensing. The system will generate a list of pending review prescriptions based on the review scheme set by the review pharmacist, and comprehensively check and alert the use of drugs through the medication rule engine (such as overdose reminders, gender-based drug use reminders, administration route, repeated medication, age-based medication, drug compatibility contraindications, etc.), and provide suggestions on whether the prescription is reasonable. If the pharmacist considers the prescription unreasonable, they can select pre-edited warning messages or manually input review opinions and return them to the physician. When the "return (double-sign)" option is selected, the physician can double-sign confirmation or modify the prescription. If not selected, the physician must modify the prescription. If the pharmacist considers the prescription reasonable, they can choose to pass the review and enter the next process. After review, the system provides traceability of the pharmacist's operation records, viewing the review records of the physician, the statistics of the pharmacist's review workload. (3) After prescription generation: After the prescription is generated, it enters drug dispensing. Through the establishment of a knowledge base that uses simple and understandable language to provide personalized medication education for outpatient patients with the same medication, different patients with the same medication will receive different medication education services. The complete usage and dosage information is printed on the list, and a QR code is printed on it. Patients can scan the QR code with their mobile phones to obtain the medication guidance on the prescription. The pharmacy department will conduct post-event random checks and evaluations of outpatient prescriptions. In the post-event evaluation module, the prescription evaluation results can be transmitted through the network to the prescribing physician. The outpatient physician workstation will automatically pop up a message box to remind the physician that there is a prescription that has been evaluated as unreasonable. In the message box, the physician can see specific information (including which patient's which prescription and the reason for unreasonableness), and can click the processing button to appeal and handle other operations. The appeal feedback content filled in by the physician will also be sent to the pharmacy department for evaluation by the pharmacist. The pharmacist will receive the physician's feedback message and handle it. 3. Results In 2003, our hospital established an information center. At the beginning of its establishment, there were about 5 to 6 staff members responsible for managing the computers and other equipment within the hospital. These devices were mainly used for non-medical functions such as hospital financial management. From 2011 to 2017, our hospital promoted the development of the EMR system from level 0 to 4 through internal demands. These demands included improving service efficiency, ensuring medical safety, and providing decision-making data. After our hospital's EMR reached level 4, we have achieved information sharing across the entire hospital and no longer have the motivation to upgrade the level. Since 2011, the National Health Commission of China has organized a national evaluation of the application level of EMR systems every year [6]. However, that was only an assessment of the single information system aspect, and it was not included in the overall assessment system of hospitals by the state. It was not until 2019 that the evaluation results were included as a core indicator in the "National Examination". This prompted our hospital to upgrade the EMR system to level 5 in 2020 and to level 6 in 2023. Level 6 is the highest level that our hospital's EMR system has reached, and it is also the highest level that an individual hospital's EMR can achieve. Once the EMR system reaches level 7, it is necessary to achieve the sharing of medical information among different regions. Here, we present a figure (Fig. 2 ) to illustrate the scenario after the EMR system reaches level 6. This figure shows the information flow within our hospital's EMR system, covering all aspects from outpatient appointments, hospitalization, discharge to subsequent follow-ups. During this process, patients can use a smartphone app to participate in the entire medical procedure. Table 3 shows the years when our hospital's EMR system reached each level, as well as the comparisons with the levels of Sichuan Province and the national average. Since 2019, due to the impetus of national power, the average level of EMR systems in all hospitals participating in the "National Examination" across the country and in Sichuan Province has only exceeded level 2. The number of hospitals with EMR system ratings at and above level 5 across the country has exceeded 100, while there are only 3 in Sichuan Province. As of 2024, there are only 4 hospitals in the country with EMR system ratings reaching level 7, and only 1 reaching level 8. There are no hospitals in Sichuan Province that have reached levels 7 or 8. This indicates that even when comparing within China, there are significant differences in the development levels of EMR systems in different regions, which is mainly related to the imbalance in economic development and the varying degrees of government financial support. However, it can be clearly seen that after participating in the "National Examination", the average level of EMR in hospitals across the country and in Sichuan Province has significantly improved. Table 3 The years when our hospital's EMR system reached each level, as well as the comparisons with the levels of Sichuan Province and the national average(2011–2024) Level Content The year when our hospital met the standards The average level of all participating hospitals across the country The number of hospitals at level 5 and above across the country The average grade of the participating hospitals in Sichuan Province The number of hospitals at level 5 and above in Sichuan Province 0 The EMR system has not been established 2011 N/A N/A N/A N/A 1 Establishment of an independent medical information system 2012 1 5–7 0.8 N/A 2 Internal exchange of medical information within the department 2013 1.3 7–10 1 N/A 3 Interdepartmental exchange of medical information 2015 1.6 15–20 1.2 N/A 4 Full hospital-wide information sharing, primary medical decision support 2017 1.5 58 1.1 N/A 5 Unified data management, intermediate medical decision support 2020 2.43 176 2 3 6 Full-process medical data closed-loop management, advanced medical decision support 2023 3.24 395 2.87 6 7 Medical safety quality control, regional medical information sharing not qualified N/A 4 N/A 0 8 Integration of health information, continuous improvement of medical safety and quality not qualified N/A 1 N/A 0 Note: The data is sourced from the official website ( https://www.niha.org.cn/ ) of the Hospital Management Institute of the National Health Commission, based on the annual national evaluation results announcements over the years. N/A indicates that the absence of relevant data or non-participation in the evaluation. 4. Discussion 4.1 Analyzing from the perspective of the developing country, the reasons for implementing the evaluation of the application level of EMR systems In 2003, China's urbanization rate was close to 40%, and it subsequently increased rapidly. By 2019, China's urbanization rate exceeded 60%, preliminarily entering the late stage of urbanization development. In 2023, China's urbanization rate reached 66.16%, marking its entry into the late stage of urbanization development [7–8]. The rapid rise in urbanization rate within a short period led to a large influx of rural populations into cities for work and settlement, resulting in an explosive growth in the number of patients in urban areas. However, as a middle- to low-income country, the increase in medical resources (such as the number of healthcare professionals) could not keep pace with the growing demand. The state had to forcefully promote informatization reforms in China's large public hospitals through institutional measures to enhance service efficiency and ensure medical safety. Second, similar to many developing countries, China has a large population and relatively insufficient investment in healthcare. By the end of 2023, China's social medical insurance covered 1.34 billion people. Total health expenditures accounted for approximately 7% of GDP (relatively low input), with government and social medical insurance expenditures making up about 73% and personal expenditures about 27%. The average life expectancy of the population reached 78.4 years (relatively high output). These data demonstrate the success of China's social medical insurance reform [9]. As the reform deepens, refined management of medical insurance funds must be strengthened, requiring medical institutions to provide authentic and detailed operational data through informatization systems. Third, with China's own development and the increase in its interactions with the world, it has been exposed to more advanced technologies and ideas. Regardless of the country, the political commitments made by the national government or the ruling party to the people regarding healthcare system reforms serve as the fundamental driving force and ultimate goal for advancing such reforms. The mainstream ideology of the government is a critical factor in determining the policy agenda. The "Healthy China 2030" Planning Outline issued by the Chinese government calls for the improvement of the population health information service system [10], with specific implementation relying on the state's mandatory assessment of EMR system applications. 4.2 Analyzing from the perspective of China, the goals that the level classification of the EMR system needs to achieve The Chinese National Health Commission implements the graded evaluation of EMR system application levels to achieve the following goals: 4.2.1 Enhancing medical quality and safety Standardizing diagnosis and treatment processes: By standardizing the recording, storage, and sharing of medical record information through EMR systems, issues such as handwriting errors and information omissions are reduced, thereby improving diagnostic and treatment accuracy. Clinical decision support: Advanced EMR systems can provide functions such as medication reminders, risk warnings, and treatment guideline recommendations, assisting doctors in making scientific decisions and reducing medical risks. Patient safety management: Through systematic management of patient information (e.g., allergy history, medication conflicts), human errors leading to medical mistakes are avoided. 4.2.2 Promoting interconnectivity and interoperability of medical data Breaking down information silos: Facilitating the sharing of EMR information across medical institutions at all levels, making it easier for patients to seek care and transfer across institutions, reducing duplicate examinations, and improving efficiency. Supporting tiered healthcare delivery: Through data interoperability, primary healthcare institutions can collaborate with higher-level hospitals, enhancing the service capacity of primary care and implementing the tiered healthcare system. 4.2.3 Optimizing the healthcare service experience Improving efficiency: Simplifying processes such as registration, payment, and report checking, thereby reducing patient waiting times. Enhancing convenience and benefits for the public: Supporting online access to medical records and remote retrieval, making it easier for patients to manage their health information. 4.2.4 Supporting hospital refined management and healthcare reform Data-driven management: By leveraging medical data accumulated through EMR systems, hospitals can analyze diagnosis and treatment patterns, resource utilization, and optimize operational management. Adapting to medical insurance payment reforms: Providing an authentic and structured data foundation for insurance payment systems and medical insurance supervision. Facilitating research and public Health: Standardized data enables clinical research, disease surveillance, and public health decision-making. 4.2.5 Guiding the scientific development of medical institution informatization Clarifying the development path: The graded evaluation provides hospitals with progressive goals (Levels 0–8) from basic functions to advanced intelligence, avoiding blind investments. Incentivizing healthy competition: By publicizing evaluation results and linking them to hospital assessments, hospitals are encouraged to proactively enhance their informatization levels. Standardizing industry norms: Unifying the functional, data, and security requirements for EMR systems promotes the healthy development of the industry. 4.3 How should hospitals respond to the increase in personnel at the information center? Although the application of the EMR system has improved the efficiency of the medical system and potentially reduced the manpower requirements of various departments in the hospital, the staff of the information center may need to increase, especially during the initial stage of system construction. How should hospitals respond to the increase in personnel at the information center? Our hospital has provided a solution. From 2003 to 2018, due to the gradual popularization of information systems in our hospital, the number of staff in the information center increased from 5 to 6 to about 20. From 2019 to 2023, in order to upgrade the system rating to level 5 or 6 and maintain the daily operation of the system, our hospital invested more funds in information construction (the total amount of funds has not been disclosed by the government), and the number of staff in the information center increased to 37. Additionally, from 2019 to 2023, as the hardware of our hospital's information system became increasingly complex, 30 personnel from system hardware companies were gradually added to assist in the maintenance and guarantee of the normal operation of computers, printers, networks, servers, and databases. With the continuous upgrading of system software, 25 personnel from system software companies were gradually added to assist in software development and operation maintenance. Up to now, the information center of our hospital has a total of 92 staff members, among whom only 37 are paid by government funds, while 55 are voluntarily dispatched by hardware and software companies for their own business development and are paid by the companies. The dispatch of company personnel to the hospital not only helps to better maintain the system operation but also enables continuous improvement and development of new systems in a real medical environment. Moreover, the success of a company's business in a large hospital is the best advertisement for it to expand other businesses. This is a good example of government and enterprise cooperation, where the government saves funds and achieves the goal of system improvement; enterprises, encouraged by the government, see hope in the industry and promote their own business. 4.4 Comparison with prior work As the earliest country in the world to implement EMR systems, the United States has a clear and mature grading evaluation system for EMR systems. It mainly promotes and implements through two core projects: "Meaningful Use" and "Promoting Interoperability Project" [11–12]. The core is to evaluate the depth and effectiveness of medical institutions' use of EMR through phased requirements and scoring systems. The "Meaningful Use" stage was the core incentive project launched by the United States under the 2009 HITECH Act, aiming to promote the adoption and effective use of EMR through economic incentives (bonuses) and penalties (health insurance payment adjustments). The "Promoting Interoperability Project" is the current project that is currently running and inherits and develops the core spirit of "Meaningful Use". It belongs to the "Quality-Based Payment Program" of the Centers for Medicare and Medicaid Services in the United States. Medical institutions must participate in this project to meet the relevant requirements, otherwise they will face negative adjustments in health insurance payments. Table 4 compares the grading evaluation systems of EMR in the United States and China. Although the United States does not have an exact numerical grading from 0 to 8, it has constructed a highly effective "grading" promotion system through legislation-driven, stage-based requirements and scoring projects that are linked to mandatory health insurance payments. Its core logic is "using economic levers to promote the standardization of clinical processes and information interconnection", which contrasts sharply with the administrative review-driven model in China. However, the administrative review results in China will also affect government funding for hospitals, donations from social funds to hospitals, and patients' choice of hospitals, ultimately influencing the economic income of hospitals. Table 4 The analogy between the "EMR System Application Level Grading Evaluation" in the United States and China Characteristics The American system The Chinese system Name The stage of meaningful use / Project for Promoting Interoperability Grading Evaluation of the Application Level of EMR Systems (0–8 Levels) Core driving force Economic incentives and penalties Administrative review and hospital rating Evaluation method Stage-based requirements + Annual scoring system (must reach the minimum score) Clarify the classification standards (from local application to full hospital-wide information sharing and intelligent support) Goal Promoting the use of EMR, facilitating information exchange, and improving medical quality and patient participation Standardize system construction, enhance the depth and breadth of applications, and ensure data quality and security Result Directly affecting the income that medical institutions receive from the medical insurance system Directly affecting the hospital's grade, reputation and administrative management evaluation Developed countries have the economic strength to implement EMR and conduct corresponding evaluation studies. Nonetheless, this is not the case for developing countries. For instance, Odikuene et al. [13] in their report on the region of sub-Saharan Africa, proposed that EMR would improve the quality of medical services in that area. Whereas, the high costs of purchasing and maintaining EMR systems have hindered their widespread adoption at present. It remains questionable whether the assessment of a technology in one country can be transferred to another country. This requires considering different healthcare systems and the different strategies implemented in medical digitization [14]. 4.5 Limitations First, there is no unified official public data available regarding the specific amount of funds allocated by China for the application of EMR systems at different levels. This investment is usually dispersed among various levels of government funds, hospital own funds, and social capital, covering multiple aspects such as hardware upgrades, software development, standard formulation, and personnel training. Second, in this current era where digitalization is ubiquitous, it is extremely challenging to evaluate the effectiveness of EMR systems through randomized controlled trials, such as determining how much resources have been saved and how much efficiency has been improved. Because it was difficult to find a suitable control group. 5. Conclusion In countries that cannot provide sufficient funds for the reform of medical informatization, a system for rating EMR and hospital assessment similar to the one in this study can be established. This will facilitate the flow of limited funds into the field of medical digital reform. Evaluation results with policy-oriented guidance and coercive power can be linked to hospital ratings, financial subsidies, medical insurance payments. Classifying EMR application levels into 0–8 grades helps hospitals understand their current stage and gaps, encourages hospitals to continuously improve system functionality and application depth through regular evaluations every year. The National Health Commission's implementation of the graded evaluation of EMR systems is not merely a technical assessment but a key initiative to shift the healthcare model from "disease-centered" to "patient-centered." The ultimate goal is to achieve safer, more efficient, and more humanized healthcare services. Declarations Ethics approval and consent to participate: Not applicable. Consent for publication: Manuscript is approved by all authors for publication. Availability of data and materials: Not applicable. Competing interests: No conflict of interest. Funding: This study was supported by Institute of Hospital Management of the National Health Commission, the "Application Research of Fully Paperless Intelligent Medical Record Management System under the Day Surgery Center Model" project of the Standardized Management of Daytime Medical Services (DSZ20251079) Authors' contributions: Lang Shu : Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing. Dan Fan: Writing – review & editing. Xinyue Wang: Writing – review & editing. Jiangrong Luo: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing, Supervision. References (Since the original Chinese literature is required for this paper, the full text cannot be retrieved in PubMed, so the references 7-10 are from China National Knowledge Infrastructure (https://www.cnki.net/), which are translated from Chinese to English by the author of this paper.) Cun Wang. The important role of international exchange in the development of medical informatics in developing countries: A report from China, Medical Informatics. 1993, 18:1, 1-10, [doi: 10.3109/14639239309034463] LI, Z. B., and GE, D. Z. The use of the computer in hospital management. Chinese Journal of Hospital Administration. 1986, 5, 290-293. “Xu Xianchun: China remains the world's largest developing country - an analysis from the perspective of purchasing power parity” Accessed: December 9, 2025. [Online]. Available: https://www.stats.gov.cn/sj/sjjd/202302/t20230202_1896345.html. “Opinions of the general office of the state council on strengthening the performance evaluation work of tertiary public hospitals （State Council document） No. 4 [2019]” Accessed: December 9, 2025. [Online]. Available: https://www.gov.cn/zhengce/content/2019-01/30/content_5362266.htm. “Notice on Issuing the Management Measures for the Grading Evaluation of the Application Level of Electronic Medical Record Systems (Trial) and the Evaluation Standards (Trial) （National Health Commission document） No. 1079 [2018]” Accessed: December 9, 2025. [Online]. Available: https://www.nhc.gov.cn/yzygj/c100068/201812/b01f63185ef74a41afa30adeb5c58ccf.shtml. “Notice from the Hospital Management Research Institute of the National Health and Family Planning Commission on the release of the results of the grading evaluation of the function application level of electronic medical record systems for high-level hospitals from 2011 to 2017” Accessed: December 9, 2025. [Online]. Available: https://niha.org.cn/prod-api/web/search/211. Cao Zehao, Yu Shubo, Wei Ling, et al. A Preliminary study on the development process of urbanization in China. Central China Architecture. 2025, 43(11): 57-60. [doi: 10.13942/j.cnki.hzjz.2025.11.021] Cui Xiaoxiang. Research on the measurement and influencing factors of high-quality urbanization development under the new development concepts. 2021. Xi'an University of Electronics and Technology, MA thesis. [doi: 10.27389/d.cnki.gxadu.2021.003401] Yang Yansui, Qin Qin, Yang Yongheng. Policy foundations and institutional innovations for realizing universal health care coverage in China. Journal of Suzhou University (Philosophy and Social Sciences Edition). 2025, 46 (01) : 44-55, [doi: 10.19563 / j.carol carroll nki SDZS. 2025.01.005] "Healthy China 2030" planning outline issued. People's Daily, 2016-10-26 (001). Institute of Medicine (U.S.). Committee on Patient Safety and Health Information Technology. Health IT and patient safety: building safer systems for better care. Washington D.C: National Academy of Sciences; 2012. Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med. 2010 Aug 05;363(6):501-504. [doi: 10.1056/NEJMp1006114] Odekunle FF, Srinivasan S, Odekunle RO. Why Sub-Saharan Africa lags in electronic health record (EHR) adoption and possible strategies to increase EHR adoption in this region. Journal of Health Informatics in Africa. 2018;5:8-15. [doi: 10.12856/JHIA-2018-v5-i1-147] Wilson K, Khansa L. Migrating to electronic health record systems: A comparative study between the United States and the United Kingdom. Health Policy. 2018 Nov;122(11):1232-1239. [doi: 10.1016/j.healthpol.2018.08.013] Additional Declarations No competing interests reported. Supplementary Files floatimage1.png GA Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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20:05:47","extension":"html","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105716,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8609608/v1/a0b14f2b8a9f97918d87c1bc.html"},{"id":101011997,"identity":"f537b50a-7aac-4dfc-abba-816df6dcefd7","added_by":"auto","created_at":"2026-01-23 20:05:47","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":302601,"visible":true,"origin":"","legend":"\u003cp\u003eGrading evolution standards for the application level of EMR systems\u003c/p\u003e","description":"","filename":"Fig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8609608/v1/82c63b4b3a12f0d55afcfdda.jpg"},{"id":101204209,"identity":"5a730a6a-b098-46cd-9a8c-ba8371cbdc9d","added_by":"auto","created_at":"2026-01-27 09:41:59","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56658,"visible":true,"origin":"","legend":"\u003cp\u003eClosed-Loop Digital Care Journey\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8609608/v1/be20a752b504cb0423704b23.jpg"},{"id":102016909,"identity":"ac479f2c-419c-47d0-a9e9-7a0129cc2ef6","added_by":"auto","created_at":"2026-02-06 07:42:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1934405,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8609608/v1/62f6a6b6-564c-4e72-8b04-1a5bb03ccf4b.pdf"},{"id":101011995,"identity":"6631af43-6b65-4a74-a4cb-4f531154ffdb","added_by":"auto","created_at":"2026-01-23 20:05:47","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":397590,"visible":true,"origin":"","legend":"\u003cp\u003eGA\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8609608/v1/cf7ff7e259baa85ea763c0a8.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"How does national power promote the improvement of the application level of electronic medical record","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe use of paper-based patient record systems has numerous drawbacks, such as being prone to loss, duplication, theft, fire damage, and being restricted for research purposes. Now we are facing a new drawback, namely that during the process of handling the records, the novel coronavirus (SARS-CoV-2) and other infectious diseases may be transmitted. In the early 1960s, the United States was the first to apply computers to hospital management and established several computerized hospital management systems. Nowadays, the EMR system is one of the main systems in hospital management information systems, and its application has become quite widespread in developed countries. Research on computerized hospital management systems in China began in the late 1970s [1]. For instance, from 1979 to 1986, the Heilongjiang Provincial Hospital established a multi-functional computerized hospital management system, which covered aspects such as medical record management, personnel file management, treatment quality assessment, medical statistics, pharmacy management and medical equipment management [2].\u003c/p\u003e \u003cp\u003eLike many developing countries, the development of EMR systems in China has been slow, due to the lack of financial support. China has a vast territory and a large population, and its economic output ranks among the top in the world. However, the per capita gross domestic product (GDP) is low and the country's investment in healthcare is insufficient. The National Bureau of Statistics of China reported that as of 2017, the total population of China was approximately 1.4\u0026nbsp;billion, accounting for about 20% of the global population. On May 19, 2020, the World Bank released the per capita GDP calculated based on the latest (2017 round) International Comparison Program. The per capita GDP of China was \u003cspan\u003e$\u003c/span\u003e14,150, which was equivalent to 23.6% of the per capita GDP of the United States in the same year. Chinese public health investment accounts for less than 8% of the GDP [3]. In order to encourage public hospitals to allocate more of their limited funds to the development of EMR systems, the National Health Commission of China included the rating of the application level of EMR systems in the performance assessment of large public hospitals in 2019.\u003c/p\u003e \u003cp\u003eSichuan Provincial People's Hospital (our hospital) is one of the pilot hospitals for this assessment. Sichuan Province covers an area of approximately 486,000 square kilometers and is the fifth largest province in China. As of 2024, its permanent resident population is 83.64\u0026nbsp;million. Our hospital is one of the large hospitals in Sichuan Province established in 1941. As of 2024, it has 4,500 beds, over 7,000 staff members, about 1,700 doctors, approximately 1.5\u0026nbsp;million outpatient visits per year, about 47,000 inpatient visits per year, and 25,000 surgeries per year. To serve such a large number of patients and staff, our hospital must enhance the application level of the EMR system to enhance service efficiency, ensure medical safety and provide decision-making data. This study reports on how our hospital has improved the application level of the EMR system from 2011 to 2024 (level 0 to 6), with a focus on analyzing how the application level of the EMR system was enhanced after our hospital participated in the performance assessment of large public hospitals by the National Health Commission in 2019 (level 5 to 6). This research provides a demonstration for developing countries lacking financial support on how to utilize national power to promote medical informatization.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatement of Significance\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProblem or Issue:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLike many low- and middle-income countries, the development of electronic medical record (EMR) systems in China was slow due to the lack of funds. It was not until 2019, when the government incorporated the evaluation of EMR systems into the assessment indicators for large public hospitals that the application of EMR systems achieved a qualitative improvement.\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat is Already Known\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe United States has a clear and mature grading evaluation system for EMR systems. Its core logic is \"using economic levers to promote the standardization of clinical processes and information interconnection\".\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWhat this Paper Adds\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProviding an administrative review-driven model in China.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWho would benefit from the new knowledge in this paper\u003c/b\u003e:\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIn countries that cannot provide sufficient funds for the reform of medical informatization, a system for rating EMR and hospital assessment similar to the one in this study can be established.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 The definition of the \"National Examination\"\u003c/h2\u003e \u003cp\u003eThe National Health Commission of China classifies China's public hospitals into three levels. The tertiary hospitals are the highest level of hospitals, usually being large hospitals in a region. Our hospital is a tertiary hospital. \"The Performance Evaluation of China's Tertiary Public Hospitals\" is abbreviated as \"National Examination\" by Chinese hospitals. It was implemented since 2019 and is the most important national hospital assessment for large public hospitals in China. It assesses all tertiary hospitals in China, with approximately 2,000 hospitals (the number changes slightly each year). It is organized and implemented by the National Health Commission and is an important mechanism for evaluating core indicators such as the hospital's comprehensive management level, medical service quality, and operational efficiency. The assessment results directly affect the country's rating of hospitals, policy support, and resource allocation, aiming to promote the high-quality development of public hospitals. The national classification of the application level of EMR systems in hospitals has been included as the sole information technology indicator for the \"National Examination\" [4]. EMR, as the core and foundation of smart hospitals, are the priority area for hospital infrastructure construction.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Grading evaluation standards for the application level of EMR systems\u003c/h2\u003e \u003cp\u003eThe \u0026ldquo;Grading evaluation standards for the application level of EMR systems\u0026rdquo; (The rating criteria were released in 2011, and were incorporated into the \"National Examination\" scoring system in 2019) [5] is divided into 9 levels ranging from 0 to 8, involving 10 job roles and 39 evaluation items \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Levels 1 to 3 are the beginner level, with the goal being the electronic collection of medical data and the internal data sharing within departments; levels 4 to 5 are the intermediate level, with the goal being the system integration of the hospital and unified data management; levels 6 to 8 are the advanced level, with the goal being the sharing of regional medical information across cities, as well as the regional medical safety and quality control.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe selection of 39 evaluation items takes into account aspects such as medical, medical technology, medical insurance, the foundation of EMR, and information utilization, and is examined from three dimensions: the functions of the system, the effective application scope of the system, and data quality. According to the requirements corresponding to the EMR application level of 0 to 8 grades, the functional requirements and evaluation contents for each evaluation item were determined. The total score of the evaluation is the sum of the scores of each item during the local evaluation, and it is a quantitative indicator reflecting the overall application situation of EMR in medical institutions. The total score should not be lower than the minimum total score standard required for that level. For example, if the EMR system of a medical institution is to be evaluated at the 3rd level, the total score must not be less than 85 points.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the general requirements for grading evaluation of the application level of EMR systems.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral requirements for grading evaluation of the application level of EMR systems\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBasic items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOptional items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMinimum total score (points)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16/19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10/23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12/25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20/32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: The basic items refer to the items that must be met at that level, while the optional items refer to the items that can be selectively met at that level. Among the optional items, \"4/17\" indicates that at least 4 out of the 17 optional items need to be met.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eN/A indicates that there are no requirements.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows an example of the specific scoring requirements of a basic item (Ward order processing) based on a job role (Physician in ward). Due to the large amount of text in the specific scoring requirements of all basic items based on all job roles, they can be obtained from the official website of the National Health Commission at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nhc.gov.cn\u003c/span\u003e\u003cspan address=\"https://www.nhc.gov.cn\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAn example of the specific scoring requirements of a basic item(Ward order processing) based on a job role (Physician in ward)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEvaluation content\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScore (points)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe physician issues medical orders manually.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(1) Issue medical orders on the computer and record them locally.\u003c/p\u003e \u003cp\u003e(2) Exchange data with other computers via disks, files.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe medical orders are transmitted via the network between the different procedures and then delivered to the nurses in the ward.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(1) The medical orders are available simultaneously for nurses, pharmacists and other staff to use via the network.\u003c/p\u003e \u003cp\u003e(2) It is possible to obtain the availability of drugs in the pharmacy department.\u003c/p\u003e \u003cp\u003e(3) There is a unified medical order item dictionary for the entire hospital.\u003c/p\u003e \u003cp\u003e(4) When the medical orders are issued, it is possible to obtain the drug formulation, dosage, or at least one type of item from the examination and inspection list that is verified and prompted according to the rules of the dictionary.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(1) The information such as drugs, tests and examinations in the medical orders can be transmitted to the corresponding executing departments.\u003c/p\u003e \u003cp\u003e(2) When the medical orders are issued, the related items can obtain drug knowledge,such as having the function of querying drug instructions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(1) Medical orders can be uniformly managed and displayed in the hospital.\u003c/p\u003e \u003cp\u003e(2) There is a control mechanism for the authority of physicians to issue drug treatment orders, and it supports the classification of antibacterial drugs usage management.\u003c/p\u003e \u003cp\u003e(3) Based on the diagnosis, the situation of infectious diseases can be determined, and it can be reported to the medical administration department through the system.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(1) There is a reporting and handling function for adverse reactions of the prescribed drugs for medical treatment orders.\u003c/p\u003e \u003cp\u003e(2) The prescribing physician can receive the evaluation results of their own prescriptions.\u003c/p\u003e \u003cp\u003e(3) When issuing medical orders, it is possible to conduct automatic checks by referring to at least 4 pieces of content from the knowledge base such as drugs, examinations, tests, drug allergies, diagnoses, gender, etc., and provide prompts.\u003c/p\u003e \u003cp\u003e(4) It is possible to monitor the status of each link of the medical order execution in real time.\u003c/p\u003e \u003cp\u003e(5) It supports electronic application and process tracking for in-hospital consultations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(1) When giving medical orders, it can automatically compare the execution and variation situations based on the clinical pathway (guidelines) requirements and the patient's specific data, prompt the input of the variation reasons and record them.\u003c/p\u003e \u003cp\u003e(2) Based on the test results, medication use, etc., it automatically issues early warnings and provides prompts for infectious diseases, hospital infection outbreaks, etc., and supports the supplementation of information and reporting to the medical administration department for confirmed infectious diseases, hospital infection outbreaks, etc.\u003c/p\u003e \u003cp\u003e(3) When giving medical orders, all medical records within the institution and relevant medical records from external medical institutions of the patient can be queried.\u003c/p\u003e \u003cp\u003e(4) Automatically conduct a verification of medical orders based on the past diagnosis and treatment situations within and outside the medical institution, and provide prompts.\u003c/p\u003e \u003cp\u003e(5) Based on the medical orders, execution status and knowledge base, automatically determine adverse event situations and provide prompts.\u003c/p\u003e \u003cp\u003e(6) Support physicians to browse medical order records outside the hospital.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIt can share patients' medical and health information and enable centralized display, including medical information within and outside the institution, health records, physical examination results, follow-up information, patients' self-collected health records (such as health records, wearable device data), etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provide detailed and clear visual representations of the differences between various levels.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 How can countries and hospitals achieve the predetermined level of EMR?\u003c/h2\u003e \u003cp\u003eThe country has established the framework (grading evaluation standards) to promote hospitals integrate and upgrade their internal systems. Each hospital uploads system data to the national data platform. Subsequently, The National Health Commission organizes expert groups to conduct online and on-site evaluations of the hospitals, and the evaluation results are made public to allow patients to understand the hospital's level. The results affect the hospital's reputation. The higher the level, the more attractive it is to patients, and it also attracts more social donations and national grants for projects such as hospital building construction and medical equipment procurement. Taking our hospital as an example, here are the steps for upgrading our EMR from level 5 to 6.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Step 1: Preparatory work\u003c/h2\u003e \u003cp\u003eThrough literature review and on-site investigation methods, we aimed to understand the functions of the mainstream EMR systems in China and the feedback on their usage. The investigation covered aspects such as the basic situation of the hospital, the number of outpatient and inpatient visits, the usage of rational drug use software, the level of application of electronic medical records, and usage suggestions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Step 2: Establish the project implementation team\u003c/h2\u003e \u003cp\u003eForm a project implementation team consisting of the hospital president, information center engineers, software manufacturer engineers, doctors, nurses, and technicians. The hospital president is responsible for controlling the entire project implementation process; the information center engineers are responsible for the overall construction of software and hardware, system operation and maintenance, and information security; the software manufacturer engineers are responsible for the development and implementation of each module of the software, as well as the design of interface technical solutions; doctors, nurses, and technicians are responsible for coordinating all parties and communicating with engineers to design appropriate software processes, etc.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3 Step 3: Project implementation (Taking rational drug use in outpatient departments as an example)\u003c/h2\u003e \u003cp\u003eThe clinical pharmacists and information center engineers jointly compare the application level standard of the EMR system at level 6, sort out all the functional points related to rational drug use in the rating standards, establish the outpatient rational drug use process and the closed-loop system for prescription data circulation. From the perspectives of patients, physicians, and drugs, analyze the key points in the three steps before, during, and after the generation of prescriptions, clearly define the functions of each module that need to be constructed, and ensure the informatization and traceability of each link in outpatient drug use.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4 Step 4:Closed-loop system construction (Taking rational drug use in outpatient departments as an example)\u003c/h2\u003e \u003cp\u003e(1) Before prescription generation: A unified rational drug use knowledge base for the entire hospital was established. When clinical physicians issue prescriptions, the system conducts real-time verification. Based on the patient's diagnosis, gender, history of drug allergies, and previous test and examination results, according to the warning information types set in the \"system settings\", the system will prompt for any unreasonable issues in the prescription. The system supports merging the prescriptions of outpatient patients for review on the same day, and when the outpatient physician issues a prescription, the system can monitor the prescriptions that the same patient has already taken in the past. The system supports pharmacists viewing real-time prescriptions and also supports clinical directors and physicians in viewing the problem prescriptions in their departments and personally.\u003c/p\u003e \u003cp\u003e(2) Prescription generation: After the prescription is saved, it will enter the rational drug use review module for rationality review before drug dispensing. The system will generate a list of pending review prescriptions based on the review scheme set by the review pharmacist, and comprehensively check and alert the use of drugs through the medication rule engine (such as overdose reminders, gender-based drug use reminders, administration route, repeated medication, age-based medication, drug compatibility contraindications, etc.), and provide suggestions on whether the prescription is reasonable. If the pharmacist considers the prescription unreasonable, they can select pre-edited warning messages or manually input review opinions and return them to the physician. When the \"return (double-sign)\" option is selected, the physician can double-sign confirmation or modify the prescription. If not selected, the physician must modify the prescription. If the pharmacist considers the prescription reasonable, they can choose to pass the review and enter the next process. After review, the system provides traceability of the pharmacist's operation records, viewing the review records of the physician, the statistics of the pharmacist's review workload.\u003c/p\u003e \u003cp\u003e(3) After prescription generation: After the prescription is generated, it enters drug dispensing. Through the establishment of a knowledge base that uses simple and understandable language to provide personalized medication education for outpatient patients with the same medication, different patients with the same medication will receive different medication education services. The complete usage and dosage information is printed on the list, and a QR code is printed on it. Patients can scan the QR code with their mobile phones to obtain the medication guidance on the prescription. The pharmacy department will conduct post-event random checks and evaluations of outpatient prescriptions. In the post-event evaluation module, the prescription evaluation results can be transmitted through the network to the prescribing physician. The outpatient physician workstation will automatically pop up a message box to remind the physician that there is a prescription that has been evaluated as unreasonable. In the message box, the physician can see specific information (including which patient's which prescription and the reason for unreasonableness), and can click the processing button to appeal and handle other operations. The appeal feedback content filled in by the physician will also be sent to the pharmacy department for evaluation by the pharmacist. The pharmacist will receive the physician's feedback message and handle it.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eIn 2003, our hospital established an information center. At the beginning of its establishment, there were about 5 to 6 staff members responsible for managing the computers and other equipment within the hospital. These devices were mainly used for non-medical functions such as hospital financial management. From 2011 to 2017, our hospital promoted the development of the EMR system from level 0 to 4 through internal demands. These demands included improving service efficiency, ensuring medical safety, and providing decision-making data. After our hospital's EMR reached level 4, we have achieved information sharing across the entire hospital and no longer have the motivation to upgrade the level. Since 2011, the National Health Commission of China has organized a national evaluation of the application level of EMR systems every year [6]. However, that was only an assessment of the single information system aspect, and it was not included in the overall assessment system of hospitals by the state. It was not until 2019 that the evaluation results were included as a core indicator in the \"National Examination\". This prompted our hospital to upgrade the EMR system to level 5 in 2020 and to level 6 in 2023. Level 6 is the highest level that our hospital's EMR system has reached, and it is also the highest level that an individual hospital's EMR can achieve. Once the EMR system reaches level 7, it is necessary to achieve the sharing of medical information among different regions.\u003c/p\u003e \u003cp\u003eHere, we present a figure (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) to illustrate the scenario after the EMR system reaches level 6. This figure shows the information flow within our hospital's EMR system, covering all aspects from outpatient appointments, hospitalization, discharge to subsequent follow-ups. During this process, patients can use a smartphone app to participate in the entire medical procedure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the years when our hospital's EMR system reached each level, as well as the comparisons with the levels of Sichuan Province and the national average. Since 2019, due to the impetus of national power, the average level of EMR systems in all hospitals participating in the \"National Examination\" across the country and in Sichuan Province has only exceeded level 2. The number of hospitals with EMR system ratings at and above level 5 across the country has exceeded 100, while there are only 3 in Sichuan Province. As of 2024, there are only 4 hospitals in the country with EMR system ratings reaching level 7, and only 1 reaching level 8. There are no hospitals in Sichuan Province that have reached levels 7 or 8. This indicates that even when comparing within China, there are significant differences in the development levels of EMR systems in different regions, which is mainly related to the imbalance in economic development and the varying degrees of government financial support. However, it can be clearly seen that after participating in the \"National Examination\", the average level of EMR in hospitals across the country and in Sichuan Province has significantly improved.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe years when our hospital's EMR system reached each level, as well as the comparisons with the levels of Sichuan Province and the national average(2011\u0026ndash;2024)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe year when our hospital met the standards\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe average level of all participating hospitals across the country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe number of hospitals at level 5 and above across the country\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe average grade of the participating hospitals in Sichuan Province\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe number of hospitals at level 5 and above in Sichuan Province\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe EMR system has not been established\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEstablishment of an independent medical information system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u0026ndash;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternal exchange of medical information within the department\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterdepartmental exchange of medical information\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u0026ndash;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull hospital-wide information sharing, primary medical decision support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnified data management, intermediate medical decision support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFull-process medical data closed-loop management, advanced medical decision support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e395\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedical safety quality control, regional medical information sharing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enot qualified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e8\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntegration of health information, continuous improvement of medical safety and quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enot qualified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: The data is sourced from the official website (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.niha.org.cn/\u003c/span\u003e\u003cspan address=\"https://www.niha.org.cn/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) of the Hospital Management Institute of the National Health Commission, based on the annual national evaluation results announcements over the years.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eN/A indicates that the absence of relevant data or non-participation in the evaluation.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e \u003cb\u003e4.1 Analyzing from the perspective of the developing country, the reasons for implementing the evaluation of the application level of EMR systems\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn 2003, China's urbanization rate was close to 40%, and it subsequently increased rapidly. By 2019, China's urbanization rate exceeded 60%, preliminarily entering the late stage of urbanization development. In 2023, China's urbanization rate reached 66.16%, marking its entry into the late stage of urbanization development [7\u0026ndash;8]. The rapid rise in urbanization rate within a short period led to a large influx of rural populations into cities for work and settlement, resulting in an explosive growth in the number of patients in urban areas. However, as a middle- to low-income country, the increase in medical resources (such as the number of healthcare professionals) could not keep pace with the growing demand. The state had to forcefully promote informatization reforms in China's large public hospitals through institutional measures to enhance service efficiency and ensure medical safety.\u003c/p\u003e \u003cp\u003eSecond, similar to many developing countries, China has a large population and relatively insufficient investment in healthcare. By the end of 2023, China's social medical insurance covered 1.34\u0026nbsp;billion people. Total health expenditures accounted for approximately 7% of GDP (relatively low input), with government and social medical insurance expenditures making up about 73% and personal expenditures about 27%. The average life expectancy of the population reached 78.4 years (relatively high output). These data demonstrate the success of China's social medical insurance reform [9]. As the reform deepens, refined management of medical insurance funds must be strengthened, requiring medical institutions to provide authentic and detailed operational data through informatization systems.\u003c/p\u003e \u003cp\u003eThird, with China's own development and the increase in its interactions with the world, it has been exposed to more advanced technologies and ideas. Regardless of the country, the political commitments made by the national government or the ruling party to the people regarding healthcare system reforms serve as the fundamental driving force and ultimate goal for advancing such reforms. The mainstream ideology of the government is a critical factor in determining the policy agenda. The \"Healthy China 2030\" Planning Outline issued by the Chinese government calls for the improvement of the population health information service system [10], with specific implementation relying on the state's mandatory assessment of EMR system applications.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4.2 Analyzing from the perspective of China, the goals that the level classification of the EMR system needs to achieve\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Chinese National Health Commission implements the graded evaluation of EMR system application levels to achieve the following goals:\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003e4.2.1 Enhancing medical quality and safety\u003c/div\u003e \u003cp\u003eStandardizing diagnosis and treatment processes: By standardizing the recording, storage, and sharing of medical record information through EMR systems, issues such as handwriting errors and information omissions are reduced, thereby improving diagnostic and treatment accuracy.\u003c/p\u003e \u003cp\u003eClinical decision support: Advanced EMR systems can provide functions such as medication reminders, risk warnings, and treatment guideline recommendations, assisting doctors in making scientific decisions and reducing medical risks.\u003c/p\u003e \u003cp\u003ePatient safety management: Through systematic management of patient information (e.g., allergy history, medication conflicts), human errors leading to medical mistakes are avoided.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003e4.2.2 Promoting interconnectivity and interoperability of medical data\u003c/div\u003e \u003cp\u003eBreaking down information silos: Facilitating the sharing of EMR information across medical institutions at all levels, making it easier for patients to seek care and transfer across institutions, reducing duplicate examinations, and improving efficiency.\u003c/p\u003e \u003cp\u003eSupporting tiered healthcare delivery: Through data interoperability, primary healthcare institutions can collaborate with higher-level hospitals, enhancing the service capacity of primary care and implementing the tiered healthcare system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003e4.2.3 Optimizing the healthcare service experience\u003c/div\u003e \u003cp\u003eImproving efficiency: Simplifying processes such as registration, payment, and report checking, thereby reducing patient waiting times.\u003c/p\u003e \u003cp\u003eEnhancing convenience and benefits for the public: Supporting online access to medical records and remote retrieval, making it easier for patients to manage their health information.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003e4.2.4 Supporting hospital refined management and healthcare reform\u003c/div\u003e \u003cp\u003eData-driven management: By leveraging medical data accumulated through EMR systems, hospitals can analyze diagnosis and treatment patterns, resource utilization, and optimize operational management.\u003c/p\u003e \u003cp\u003eAdapting to medical insurance payment reforms: Providing an authentic and structured data foundation for insurance payment systems and medical insurance supervision.\u003c/p\u003e \u003cp\u003eFacilitating research and public Health: Standardized data enables clinical research, disease surveillance, and public health decision-making.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003e4.2.5 Guiding the scientific development of medical institution informatization\u003c/div\u003e \u003cp\u003eClarifying the development path: The graded evaluation provides hospitals with progressive goals (Levels 0\u0026ndash;8) from basic functions to advanced intelligence, avoiding blind investments.\u003c/p\u003e \u003cp\u003eIncentivizing healthy competition: By publicizing evaluation results and linking them to hospital assessments, hospitals are encouraged to proactively enhance their informatization levels.\u003c/p\u003e \u003cp\u003eStandardizing industry norms: Unifying the functional, data, and security requirements for EMR systems promotes the healthy development of the industry.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.3 How should hospitals respond to the increase in personnel at the information center?\u003c/h2\u003e \u003cp\u003eAlthough the application of the EMR system has improved the efficiency of the medical system and potentially reduced the manpower requirements of various departments in the hospital, the staff of the information center may need to increase, especially during the initial stage of system construction. How should hospitals respond to the increase in personnel at the information center? Our hospital has provided a solution.\u003c/p\u003e \u003cp\u003eFrom 2003 to 2018, due to the gradual popularization of information systems in our hospital, the number of staff in the information center increased from 5 to 6 to about 20. From 2019 to 2023, in order to upgrade the system rating to level 5 or 6 and maintain the daily operation of the system, our hospital invested more funds in information construction (the total amount of funds has not been disclosed by the government), and the number of staff in the information center increased to 37. Additionally, from 2019 to 2023, as the hardware of our hospital's information system became increasingly complex, 30 personnel from system hardware companies were gradually added to assist in the maintenance and guarantee of the normal operation of computers, printers, networks, servers, and databases. With the continuous upgrading of system software, 25 personnel from system software companies were gradually added to assist in software development and operation maintenance. Up to now, the information center of our hospital has a total of 92 staff members, among whom only 37 are paid by government funds, while 55 are voluntarily dispatched by hardware and software companies for their own business development and are paid by the companies. The dispatch of company personnel to the hospital not only helps to better maintain the system operation but also enables continuous improvement and development of new systems in a real medical environment. Moreover, the success of a company's business in a large hospital is the best advertisement for it to expand other businesses. This is a good example of government and enterprise cooperation, where the government saves funds and achieves the goal of system improvement; enterprises, encouraged by the government, see hope in the industry and promote their own business.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Comparison with prior work\u003c/h2\u003e \u003cp\u003eAs the earliest country in the world to implement EMR systems, the United States has a clear and mature grading evaluation system for EMR systems. It mainly promotes and implements through two core projects: \"Meaningful Use\" and \"Promoting Interoperability Project\" [11\u0026ndash;12]. The core is to evaluate the depth and effectiveness of medical institutions' use of EMR through phased requirements and scoring systems. The \"Meaningful Use\" stage was the core incentive project launched by the United States under the 2009 HITECH Act, aiming to promote the adoption and effective use of EMR through economic incentives (bonuses) and penalties (health insurance payment adjustments). The \"Promoting Interoperability Project\" is the current project that is currently running and inherits and develops the core spirit of \"Meaningful Use\". It belongs to the \"Quality-Based Payment Program\" of the Centers for Medicare and Medicaid Services in the United States. Medical institutions must participate in this project to meet the relevant requirements, otherwise they will face negative adjustments in health insurance payments.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e compares the grading evaluation systems of EMR in the United States and China. Although the United States does not have an exact numerical grading from 0 to 8, it has constructed a highly effective \"grading\" promotion system through legislation-driven, stage-based requirements and scoring projects that are linked to mandatory health insurance payments. Its core logic is \"using economic levers to promote the standardization of clinical processes and information interconnection\", which contrasts sharply with the administrative review-driven model in China. However, the administrative review results in China will also affect government funding for hospitals, donations from social funds to hospitals, and patients' choice of hospitals, ultimately influencing the economic income of hospitals.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe analogy between the \"EMR System Application Level Grading Evaluation\" in the United States and China\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe American system\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe Chinese system\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eName\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe stage of meaningful use / Project for Promoting Interoperability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGrading Evaluation of the Application Level of EMR Systems (0\u0026ndash;8 Levels)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCore driving force\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEconomic incentives and penalties\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdministrative review and hospital rating\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEvaluation method\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStage-based requirements\u0026thinsp;+\u0026thinsp;Annual scoring system (must reach the minimum score)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClarify the classification standards (from local application to full hospital-wide information sharing and intelligent support)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGoal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePromoting the use of EMR, facilitating information exchange, and improving medical quality and patient participation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStandardize system construction, enhance the depth and breadth of applications, and ensure data quality and security\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResult\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDirectly affecting the income that medical institutions receive from the medical insurance system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDirectly affecting the hospital's grade, reputation and administrative management evaluation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDeveloped countries have the economic strength to implement EMR and conduct corresponding evaluation studies. Nonetheless, this is not the case for developing countries. For instance, Odikuene et al. [13] in their report on the region of sub-Saharan Africa, proposed that EMR would improve the quality of medical services in that area. Whereas, the high costs of purchasing and maintaining EMR systems have hindered their widespread adoption at present. It remains questionable whether the assessment of a technology in one country can be transferred to another country. This requires considering different healthcare systems and the different strategies implemented in medical digitization [14].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Limitations\u003c/h2\u003e \u003cp\u003eFirst, there is no unified official public data available regarding the specific amount of funds allocated by China for the application of EMR systems at different levels. This investment is usually dispersed among various levels of government funds, hospital own funds, and social capital, covering multiple aspects such as hardware upgrades, software development, standard formulation, and personnel training. Second, in this current era where digitalization is ubiquitous, it is extremely challenging to evaluate the effectiveness of EMR systems through randomized controlled trials, such as determining how much resources have been saved and how much efficiency has been improved. Because it was difficult to find a suitable control group.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eIn countries that cannot provide sufficient funds for the reform of medical informatization, a system for rating EMR and hospital assessment similar to the one in this study can be established. This will facilitate the flow of limited funds into the field of medical digital reform. Evaluation results with policy-oriented guidance and coercive power can be linked to hospital ratings, financial subsidies, medical insurance payments. Classifying EMR application levels into 0\u0026ndash;8 grades helps hospitals understand their current stage and gaps, encourages hospitals to continuously improve system functionality and application depth through regular evaluations every year. The National Health Commission's implementation of the graded evaluation of EMR systems is not merely a technical assessment but a key initiative to shift the healthcare model from \"disease-centered\" to \"patient-centered.\" The ultimate goal is to achieve safer, more efficient, and more humanized healthcare services.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eManuscript is approved by all authors for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eNo conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was supported by Institute of Hospital Management of the National Health Commission, the \"Application Research of Fully Paperless Intelligent Medical Record Management System under the Day Surgery Center Model\" project of the Standardized Management of Daytime Medical Services (DSZ20251079)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLang Shu\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDan Fan:\u003c/strong\u003e Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eXinyue Wang:\u003c/strong\u003e Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJiangrong Luo:\u003c/strong\u003e Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review \u0026amp; editing, Supervision.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(Since the original Chinese literature is required for this paper, the full text cannot be retrieved in PubMed, so the references 7-10 are from China National Knowledge Infrastructure (https://www.cnki.net/), which are translated from Chinese to English by the author of this paper.)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003col\u003e\n\u003cli\u003eCun Wang. The important role of international exchange in the development of medical informatics in developing countries: A report from China, Medical Informatics. 1993, 18:1, 1-10, [doi: 10.3109/14639239309034463]\u003c/li\u003e\n\u003cli\u003eLI, Z. B., and GE, D. Z. The use of the computer in hospital management. Chinese Journal of Hospital Administration. 1986, 5, 290-293.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;Xu Xianchun: China remains the world's largest developing country - an analysis from the perspective of purchasing power parity\u0026rdquo; Accessed: December 9, 2025. [Online]. Available: https://www.stats.gov.cn/sj/sjjd/202302/t20230202_1896345.html.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;Opinions of the general office of the state council on strengthening the performance evaluation work of tertiary public hospitals （State Council document） No. 4 [2019]\u0026rdquo; Accessed: December 9, 2025. [Online]. Available: https://www.gov.cn/zhengce/content/2019-01/30/content_5362266.htm.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;Notice on Issuing the Management Measures for the Grading Evaluation of the Application Level of Electronic Medical Record Systems (Trial) and the Evaluation Standards (Trial) （National Health Commission document） No. 1079 [2018]\u0026rdquo; Accessed: December 9, 2025. [Online]. Available: https://www.nhc.gov.cn/yzygj/c100068/201812/b01f63185ef74a41afa30adeb5c58ccf.shtml.\u003c/li\u003e\n\u003cli\u003e\u0026ldquo;Notice from the Hospital Management Research Institute of the National Health and Family Planning Commission on the release of the results of the grading evaluation of the function application level of electronic medical record systems for high-level hospitals from 2011 to 2017\u0026rdquo; Accessed: December 9, 2025. [Online]. Available: https://niha.org.cn/prod-api/web/search/211.\u003c/li\u003e\n\u003cli\u003eCao Zehao, Yu Shubo, Wei Ling, et al. A Preliminary study on the development process of urbanization in China. Central China Architecture. 2025, 43(11): 57-60. [doi: 10.13942/j.cnki.hzjz.2025.11.021]\u003c/li\u003e\n\u003cli\u003eCui Xiaoxiang. Research on the measurement and influencing factors of high-quality urbanization development under the new development concepts. 2021. Xi'an University of Electronics and Technology, MA thesis. [doi: 10.27389/d.cnki.gxadu.2021.003401]\u003c/li\u003e\n\u003cli\u003eYang Yansui, Qin Qin, Yang Yongheng. Policy foundations and institutional innovations for realizing universal health care coverage in China. Journal of Suzhou University (Philosophy and Social Sciences Edition). 2025, 46 (01) : 44-55, [doi: 10.19563 / j.carol carroll nki SDZS. 2025.01.005]\u003c/li\u003e\n\u003cli\u003e\"Healthy China 2030\" planning outline issued. People's Daily, 2016-10-26 (001).\u003c/li\u003e\n\u003cli\u003eInstitute of Medicine (U.S.). Committee on Patient Safety and Health Information Technology. Health IT and patient safety: building safer systems for better care. Washington D.C: National Academy of Sciences; 2012.\u003c/li\u003e\n\u003cli\u003eBlumenthal D, Tavenner M. The \"meaningful use\" regulation for electronic health records. N Engl J Med. 2010 Aug 05;363(6):501-504. [doi: 10.1056/NEJMp1006114]\u003c/li\u003e\n\u003cli\u003eOdekunle FF, Srinivasan S, Odekunle RO. Why Sub-Saharan Africa lags in electronic health record (EHR) adoption and possible strategies to increase EHR adoption in this region. Journal of Health Informatics in Africa. 2018;5:8-15. [doi: 10.12856/JHIA-2018-v5-i1-147]\u003c/li\u003e\n\u003cli\u003eWilson K, Khansa L. Migrating to electronic health record systems: A comparative study between the United States and the United Kingdom. Health Policy. 2018 Nov;122(11):1232-1239. [doi: 10.1016/j.healthpol.2018.08.013]\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"electronic medical record, medical digital reform, low- and middle-income countries","lastPublishedDoi":"10.21203/rs.3.rs-8609608/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8609608/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLike many low- and middle-income countries, the development of electronic medical record (EMR) systems in China was slow due to the lack of funds. It was not until 2019, when the government incorporated the evaluation of EMR systerms into the assessment indicators for large public hospitals that the application of EMR systems achieved a qualitative improvement. Our hospital was one of the pilot hospitals for this reform.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe National Health Commission of China has divided the application level of EMR systems into 9 levels. Levels 1 to 3 are the beginner level, with the goal being the electronic collection of medical data and the internal data sharing within departments; levels 4 to 5 are the intermediate level, with the goal being the system integration of the hospital and unified data management; levels 6 to 8 are the advanced level, with the goal being the sharing of regional medical information across cities, as well as the regional medical safety and quality control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom 2011 to 2017, our hospital promoted the development of the EMR system from level 0 to 4 through internal demands. After 2019, the national power prompted our hospital to raise the EMR system to level 5 in 2020 and level 6 in 2023. In 2012, 2020 and 2023, the average level of EMR systems in hospitals participating in the \"National Examination\" across the country was 1, 2.43 and 3.24; The number of hospitals with EMR system ratings at and above level 5 was 5–7,176 and 395.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn countries that cannot provide sufficient funds for the reform of medical informatization, a system for rating EMR and hospital assessment similar to the one in this study can be established.\u003c/p\u003e","manuscriptTitle":"How does national power promote the improvement of the application level of electronic medical record","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-23 20:05:41","doi":"10.21203/rs.3.rs-8609608/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3cc7890c-ca06-4cd4-9711-191161465016","owner":[],"postedDate":"January 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-06T07:41:25+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-23 20:05:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8609608","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8609608","identity":"rs-8609608","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}