Below is a real selection note from a hospital that develops its own medical records :
In the construction of hospital information systems, the selection of electronic medical record controls may seem like a small but insignificant step, but in reality, it has far-reaching consequences .
Many hospitals that have pursued the self- developed electronic medical record route share the same sentiment: choosing the wrong control can lead to minor issues like doctors complaining about its difficulty in use and poor medical record quality, or even major problems like stalled rating reviews and wasted data governance efforts. Our hospital stumbled on this path three times and changed the control three times, until we encountered the Nanjing Duchang electronic medical record control, which finally brought us stability—and we've been using it for many years.
What's even more remarkable is that the more you use it, the more you discover that it's not just an editing tool that you can "write the medical records and then throw them away," but rather a core engine that reveals more and more surprises the more you dig into it and can support the management of the entire hospital.
, we thought that the control only needed to "write medical records".
When we first started making electronic medical records, our needs were very simple: to be able to use templates, to be able to input data in a structured way, to be able to store documents stably, to reduce the amount of repetitive content written by doctors, and to meet basic statistical requirements.
Back then, we treated controls as a "standard tool," choosing whichever was cheapest and had the most basic functions. As a result, we switched to three different vendors, but they were either inflexible in terms of template customization, had interfaces that couldn't keep up with our self- developed system, or had poor stability and frequent problems. We spent a lot of money and encountered many pitfalls.
Our first impression of Nanjing Duchang Controls was its comprehensive functionality, complete interfaces, and smooth integration with our self- developed system. However, initially we only used about one-tenth of its capabilities: saving doctors time by adjusting templates , allowing departments to customize their own formats, and enabling administrators to view writing progress. Efficiency was indeed improved, but at the time we thought, "That's about it, it's just a medical record editor."
Second, being forced to delve deeper into its functions revealed its hidden "secret weapon" for quality control.
What truly changed perceptions was the increasingly detailed requirements for electronic medical record rating, hospital accreditation , and national examinations in recent years, which placed direct pressure on the information technology department to manage medical quality.
For example, the most troublesome issue is the recording of critical values : according to the core system, a record must be kept in the medical history after a critical value is treated , but doctors are too busy with clinical work, and it is common for them to miss or forget to record it. In the past, the quality control department relied on random checks afterward, but by the time problems were discovered, it was already too late, the rectification cost was high, and it was easy to cause medical risks.
With a try-it-out mentality, we dug out the function manual of Duchang Controls and immediately focused on the two capabilities of "positioning and inserting information" and "elements cannot be deleted".
We quickly devised a solution: after doctors fill in the critical value management measures in the system, the relevant records are automatically and forcibly inserted into the daily medical records and cannot be manually deleted. Doctors don't need to perform any extra steps; all the necessary records are maintained without increasing the clinical burden at all.
This single function directly solves the problem of missing critical values at its root.
Following this line of thought, we implemented dozens of scenarios in one go: VTE risk assessment, imaging result analysis, medical insurance restricted drug use records, pre-transfusion assessment and plan... All management requirements that are "must be written and easy to forget" are pre-embedded in the template through controls, guiding doctors to complete them naturally.
The quality of the medical records has visibly improved, and we feel much more at ease when facing various inspections and reviews.
Third, a single authorization is valid throughout the entire hospital, offering significantly better value than expected.
the engineering and technical staff of Duchang , they casually mentioned: "The authorization is calculated on a hospital-by-hospital basis, not on a system-by-system basis."
This statement opened up a new way of thinking for us—it's like paying one price and being able to use all the systems in the entire hospital.
We initially expanded to outpatient medical records. Previously, outpatient medical records were often criticized as being like "incomprehensible gibberish"—the format was messy, readability was poor, and subsequent data was unusable. After integrating the Duchang control for structuring, the standardization of outpatient medical records improved significantly, laying the foundation for subsequent scientific research analysis and data governance.
Later, when we were applying for Level 5 review of electronic medical records, the structured nature of the examination reports was a key requirement. We directly incorporated the controls into the examination report system, and all examination findings and diagnostic recommendations were standardized and structured, thus successfully meeting the requirements.
of various record sheets and assessment forms into the nursing documentation system, both writing efficiency and standardization have improved, and the nursing department has given particularly positive feedback.
From inpatient to outpatient, from clinical to medical technology and nursing, a single control unit supports the underlying editing capabilities of the entire hospital's document system, truly achieving one-time investment and full-scenario reuse. This investment is definitely worthwhile.
IV. An underrated feature that has solved a major problem of privacy leaks
In recent years, the requirements for patient privacy protection have become increasingly stringent, and the Data Security Law and the Personal Information Protection Law have been implemented one after another. However, the situation of medical staff taking screenshots of medical records at will has been repeatedly prohibited but not stopped. Once leaked, it is difficult to hold people accountable and the risks are high. This is a chronic problem in the information technology department.
While exploring the features, we unexpectedly discovered that the Duchang control has a built-in digital watermarking capability.
Once enabled, the medical record interface will automatically display a dynamic watermark containing the operator's information and a timestamp. Leaving aside the ease of accountability, the watermark alone has a strong deterrent effect, reducing the likelihood of indiscriminate photo taking and dissemination by more than half.
Technological means plugged management loopholes, which not only implemented compliance requirements but also helped medical staff to keep a tight rein on privacy protection, resulting in a true win-win situation for both technology and management.
Fifth, a good product is a long-term partner that becomes more valuable with use.
After using them for so many years, what gives us the most peace of mind is that Duchang's products have always kept pace with the industry.
Moreover, Nanjing Duchang's control supports domestic OFD , which is of great significance to electronic medical records. Whether it is for long-term archiving or future scenarios such as Internet hospitals and regional medical sharing, OFD is a core trend. Keeping up with this standard is equivalent to paving the way for the future.
With the integration of the Duchang editor and AI technology , as well as the optimization of the mobile terminal , this "old partner" that has been with us for many years has also helped us solve many problems.
Looking back on this journey, our understanding of electronic medical record controls has completely changed:
It is no longer a simple editing tool, but a core foundational capability that supports medical quality, ensures information security, and drives refined management. It is a real strategic resource in hospital informatization.
Therefore, choosing a product that can grow alongside the hospital is more important than anything else.
E ND
Thank you to this customer for sharing their honest feedback.
According to Nanjing Duchang, a good electronic medical record control is never a one-off tool that ends with delivery, but a long-term partner that can become more valuable as hospital informatization deepens.
From structured medical record editing to intelligent medical quality control, to hospital-wide document coverage and information security protection, as well as support for OFD format and AI medical record editors , we have always been iterating our products around the real needs of hospitals, providing stable and reliable underlying support for hospital informatization .
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