临床信息标准化与电子病历深化应用的研究.pdfVIP

信息化论坛 Information Forum 临床信息标准化与电子病历深化应用的研究 ① ① ② ③ ④ ＊ 卢敬泰 吕晓娟 程钦安 张嘉俊 李伟 蒲卫 摘 要 针对目前国内医院在用信息系统普遍存在标准化程度不高，国家或地区卫生信息与健康档案信息难以实现数据共享 和大数据分析、行业“电子病历系统”产品智能化水平不高、电子病历文书数据架构难以实现高效统计分析和为临床科研服 务等问题，研究临床信息标准化、电子病历系统智能化功能拓展及电子病历文书的深化应用，以解决或逐步改善以上存在的 问题。该研究在具体实践中取得了明显效果。 关键词 临床信息标准化 电子病历 临床集成平台 临床数据中心 临床决策支持系统 Doi:10.3969/j.issn.1673-7571.2017.03.005 [中图分类号] R319;TP391 [文献标识码] A Research on the Clinical Information Standardization and the Application of Electronic Medical Records / LU Jing-tai, LV Xiao- juan, CHENG Qin-an, et al//China Digital Medicine.-2017 12(3): 12 to 14 Abstract As there are no industry standards for the information system in the hospitals of China, data sharing and analyzing are difficult to do among the nation or regions at present. The products of electronic medical records (EMR) are still inflexible. The data structures of EMR cannot support the efficient statistics, so that the clinical research based on it hardly evolves. Our work is trying to get rid of these problems. By doing the standardization of the clinical data, extending the intelligent functions of the EMR system, and applying the information techniques to improve the treatment in the hospitals of China, we obtain the significant positive results in our case. Keywords clinical information standardization, electronic medical record, clinical integration platform, clinical data repository (CDR), clinical decision support system (CDSS) Corresponding author Health Information Center of PLA, Beijing 100842, P.R.C. 1 引言 2000年以来是我国医院数字化建设的快速发展期，但我国卫生信息行业出台相关的标准较少，因此，各厂家开发的医 院信息系统（HIS）