电子病历受控术语结构与质量的评价

电子病历是数字化医疗的基础。虽然我国关于电子病历文档类型和文档段标识已有相关标准和规范,但仍缺乏电子病历文档内容和术语的标准和规范,难以纠正不同级别的医疗机构同一文档段的记录内容在结构和术语使用上的巨大差异,也无法利用大数据信息挖掘、知识发现等IT新技术,对我国丰富的电子病历数据资源库进行有效的二次利用。本文介绍了电子病历中单词、术语与受控术语的相关概念、用途和重要性,列举了患者主诉与临床检查结果表达的术语结构的概念框架,通过受控医学词汇结构与质量评价的12条评价要点,强调了电子病历内容结构与受控术语结构的标准化,在我国电子病历标准化工作中的重要性和紧迫性。     

HL7互操作框架与语义标准需求分析

为了促进标准和规范的一致性使用,实现全面的互操作性,HL7提出了互操作框架（Services-Aware Interoperability Framework,SAIF）。其中的信息框架关注静态语义,描述了概念及其组成、受控术语、非编码概念、数据类型、类、术语绑定、信息模型、模板等信息标准相关构件。综合分析SAIF和国内外卫生信息标准现状,促进语义互操作的标准应包括医学术语系统、信息模型、数据元及数据集标准、模板及文档规范等类型,各类标准之间密切关联,相互依赖。因此,各类标准的开发应保持协调和同步。我国目前主要的语义标准需求包括健全数据标准体系、建立元数据维护机制;规划和逐步建立满足临床信息化需要的医学术语系统。     

医院等级评审信息平台数据标准化研究

标准化是实现医院等级评审系统自动评分的前提条件,文章主要从数据元标准化、数据字典、病案信息标准、电子病历标准等几个方面,参考目前已出台的与标准化相关的政策如《电子病历基本架构与数据标准(试行)》、《卫生信息数据集元数据规范》、《卫生信息数据集分类与编码原则》等,探讨医院等级评审信息平台的数据标准化。     

国家卫生和计划生育委员会通告 国卫通[2016]12号

正现发布《电子病历共享文档规范第1部分:病历概要》等57项卫生行业标准,其编号和名称如下:WS/T 500.1-2016电子病历共享文档规范第1部分:病历概要WS/T 500.2-2016电子病历共享文档规范第2部分:门(急)诊病历WS/T 500.3-2016电子病历共享文档规范第3部分:急诊留观病历WS/T 500.4-2016电子病历共享文档规范第4部分:西药处方     

基于HL7CDA标准的电子病历临床文档研究

本文论述了电子病历系统的边界范围、标准化关键技术,从分析临床文档语义框架的层次结构人手,给出了基于HL7 CDA标准的临床文档语义描述,为设计、实施标准化、结构化的电子病历系统奠定了语义建构的基础.     

浅谈电子病历及其实施的相关技术问题

本文主要阐述了电子病历的结构、安全性、隐私性及保密性以及电子病历的存储体系及备份：对建立医生工作站系统、电子病历数据交换标准化、病历数据交换标准与方法等相关技术问题进行了探讨。     

EMR适于数据挖掘构建临床路径的数据特征分析

通过深入剖析卫生部下发的相关临床路径及《电子病历基本架构与数据标准》相关内容,从数据特征视角入手,探讨了电子病历适于数据挖掘方法构建临床路径的数据特征,从电子病历数据内容及数据结构两方面分析了基于电子病历的数据挖掘方法构建临床路径的可行性.     

实施结构化电子病历推动数字化医院建设

本文从分析电子病历(EMR)的概念与发展历程入手,指出结构化是EMR发展的必然方向;通过对《电子病历基本架构与数据标准》的解析,阐述了实施结构化EMR系统的相关待解决问题及其实现目标,进一步强调了结构化EMR在推动数字化医院建设中的重要性。     

临床数据传输数据组和数据元标准的研究

目的在国家已颁布的一系列数据标准的基础上,定义临床传输数据的结构与数据元组。方法采用数据建模的方法,将散落在不同卫生信息标准中的数据元、数据元值域代码和外部术语组成有完整临床含义的数据组。结果临床信息传输数据组、数据元与元数据整体架构图;形成18个数据组,131个数据元,其中124个都已在WS363和WS364定义,并增加了7个自定义数据元。结论需要传输的数据是对电子病历核心数据的抓取,电子病历的标准化是临床传输信息标准化的基础。传输信息也可以二次录入。18个数据组和131个数据元是临床数据传输的核心数据组和数据元,可在此基础上,增加相应专科、专病的数据组和数据元。     

元数据结构与数据元标准化

数据元标准化是标准化工作的基础，是实现卫生信息共享和利用的重要保证。元数据提供的是理解和精确解释数据元所需要的信息，是数据元标准的载体。本文根据相关元数据规范和国际标准ISO／IEC11179——信息技术／元数据注册，提出了卫生信息领域主要元数据的类型，包括数据元、对象类、特性、数据元概念、表示、值域、术语、数据集等，用元数据结构图表达了各类元数据及其相互关系，并依据中国卫生信息标准化现状和需求，结合实例展示了数据元标准的属性条目及其描述。     

Evolving to clinical terminology

The electronic medical record (EMR) is slowly replacing the paper chart for documenting patient details. As the adoption curve for EMRs rapidly increases, so will the need for clinical terminologies. Currently, administrative classifications such as ICD-9-CM, CPT and HCPCS serve not only billing and reporting purposes, but also are used by healthcare providers for documentation and capturing patient procedures and problem lists. But the use of clinical terminologies, such as SNOMED CT, will assume the interface role in EMRs and thus replace these administrative classifications at the point of care. These billing terminologies will then be relegated back to the coders and payers for use, enabling the clinicians to document using richer and more granular terminologies. During this transition phase to the clinical terminology, training will likely be required as healthcare providers adjust to using terminologies in more robust ways. Clinical informaticists and early adopters will play a role in this training and help to demonstrate the many advantages of richer documentation. The use of clinical standards in EMRs is one of the key evolutions in informatics.     

中文科技期刊术语规范化现状:调查与分析

【目的】 对术语使用情况进行调研,找出术语使用不规范的问题,为提升我国科技期刊术语规范化水平、推进科技期刊高质量发展提供依据。【方法】 采用回顾性调查方法,选择18种科技期刊2020年全年刊出的所有文章,调查其中术语使用差错情况。【结果】 术语相关差错主要涉及术语使用规范问题、术语编校规范问题及专有名词术语规范问题,具体差错类型比较多样化,不利于期刊质量及影响力的提升,应引起论文作者及期刊工作者的高度重视。术语相关差错中,术语使用规范问题最为突出;术语使用规范问题的各种类型中,术语形音义相近而误的现象最为突出。【结论】 我国科技期刊术语规范化水平有待提升,需要引起重视。     

电子病历的数据结构和存储

在电子病历开发中,重视电子病历的数据结构和存储的分析研究,有利于提高电子病历的整体水平。文章将从医院数据结构的特点出发,对电子病历的数据结构和存储进行初步探讨。并对基于XML树型结构的电子病历在关系型数据库和原生XML数据库中的存储进行比较和分析。     

我国基本公共卫生服务标准化现状分析暨均等化的标准化策略初探

通过对基本公共卫生服务工作标准现状与基本公共卫生服务均等化项目和首批国家基本公共服务标准化试点项目的系统分析,了解我国基本公共卫生服务标准化的现状,探讨提出实现基本公共卫生服务均等化的标准化策略建议。收集国家基本公共卫生服务上述3个方面的内容,并将公共卫生标准与《国家基本公共卫生服务规范（第三版）》所包含的14项规范和《关于开展国家基本公共服务标准化试点工作的通知》中所包含的51项国家基本公共服务标准化试点项目进行系统比较。现行公共卫生标准基本符合国家基本公共卫生服务项目中的居民健康档案管理服务规范工作需要。然而,其余13项规范以及国家基本公共服务标准化试点项目中的公共卫生项目对应的公共卫生标准不健全或缺失。现行公共卫生领域标准与实施国家基本公共卫生服务项目存在较大差距。在实现基本公共卫生均等化的进程中,亟需根据基本公共卫生服务项目的相关内容,制定与之相配套的公共卫生领域标准,助推基本公共卫生服务均等化。     

Rating the digital help: electronic medical records,software providers,and physicians

To separate the effects of physicians’ characteristics on the perceived productivity of EMRs from the effects of limitations on usability inherent in EMR design, a multivariate regression model is used to estimate the factors influencing physicians’ rankings of five attributes of their EMRs, namely; ease of use and reliability; the EMRs effect on physician and staff productivity and the EMRs performance vs. vendor’s promises. We divide the factors influencing the rankings into three groups: physician characteristics, EMR characteristics and practice characteristics (type of practice, size, and location). The data are from approximately 1800 practicing physicians in Arizona. Physician’s characteristics influence perceived ease of use and physicians’ productivity, but not staff productivity, reliability or vendors’ promised performance. Practice type and EMR characteristics affect perceived productivity, reliability and performance versus vendors’ promises. Vendor-specific effects are highly correlated across all five attributes and are always jointly significant. EMR characteristics are the most significant influence on physicians’ perceptions of the EMRs effect on their productivity and that of their staff. Physicians’ characteristics (particularly age) have a small but significant influence on perceived productivity.     

If electronic medical records are so great,why aren't family physicians using them?

OBJECTIVE: The chasm theory of marketing states that fundamental differences exist between early adopters of technology and the mainstream marketplace, making it difficult for technology to transition to the mainstream market. We investigated possible differences in attitudes and beliefs about electronic medical records (EMRs) between current EMR users (early market) and nonusers (mainstream market). STUDY DESIGN: Cross-sectional mail survey. POPULATION: Active members in the Indiana Academy of Family Physicians 2000-2001 membership database (N = 1328). OUTCOMES MEASURED: Differences in attitudes, beliefs, and demographic characteristics of EMR users and nonusers. RESULTS: The overall return rate was 51.7%; 14.4% of respondents currently use an EMR. Electronic medical record users were more likely to practice in urban areas or to be hospital-based and reported seeing fewer patients. Nonusers were less likely to believe that (1) physicians should computerize their medical records; (2) current EMRs are a useful tool for physicians; (3) EMRs improve quality of medical records and decrease errors; and (4) it is easy to enter data into current EMRs. Nonusers were more likely to believe that paper records are more secure and more confidential than EMRs. Both users and nonusers believed that current EMRs are too expensive. CONCLUSIONS: A chasm exists between EMR users and nonusers regarding issues that affect EMR implementation, including necessity, usefulness, data entry, cost, security and confidentiality. To reach full implementation of EMRs in family medicine, organizations should use these data to target their research, education, and marketing efforts.     

The adoption level of electronic medical records in hebron hospitals based on the electronic medical record adoption model (EMRAM)

BackgroundElectronic Medical Records (EMRs) have become a priority for hospitals, and assessing the level of deployment of EMRs nationwide is essential to better utilization. The Electronic Medical Record Adoption Model (EMRAM) is one of the widely used EMR assessment systems worldwide.ObjectivesStudy aims at assessing the adoption level of EMRs in Palestine using the EMRAM model, specifically Hebron city hospitals, as a case study.MethodsUsing a semi-structured interview as a research instrument, a total of 5 interviews were conducted with IT directors responsible for EMR systems used by all of the 5 hospitals in Hebron.ResultsOur study showed that EMRs in Hebron have a low level of EMR capabilities. Besides, we found Hebron public hospital is better than the private ones in adopting EMRs.RecommendationsPalestinian hospitals are advised to invest more in their EMR systems to gain more capabilities. Besides, the Palestinian Ministry of Health and the Palestinian government should encourage hospitals to proceed.     

Electronic medical records and medical procedure choice: Evidence from cesarean sections

This paper examines how hospital adoption of electronic medical records (EMRs) impacts medical procedure choice in the context of cesarean section deliveries. It provides a unique contribution by tying the literature on EMR diffusion to the literature on the utilization of expensive medical technology and provider practice style. Exploiting within‐hospital variation in three types of EMR adoption, we find that computerized physician order entry, an advanced EMR system that typically incorporates decision support, reduces C‐section rates for low‐risk mothers by 2.5%. Obstetric‐specific EMR systems and physician documentation have no statistically significant effect on C‐section rates. In addition, we find that the computerized practitioner order entry effect occurs predominantly in hospitals that were already performing fewer C‐sections and does not change the behavior of already high‐intensity providers.     

Inefficiencies of electronic medical record use by surgical healthcare providers

ObjectivesElectronic medical records (EMRs) are intended to reduce healthcare costs and improve quality of care. Nevertheless, usability issues common to EMRs have been noted. Given the time demands of a clinic and surgery schedule, as well as the association between EMR usage and burnout, continued investigation into the utility of EMRs is important. We investigated the number of login encounters and time expended on EMRs by surgeons and advanced practice providers (APPs) across several surgical specialties.MethodsA one-year retrospective study was conducted at a tertiary pediatric hospital utilizing EMR data for surgeons and surgical APPs. Encounters and hours expended on EMR were calculated and stratified into three categories: within working hours, after-hours during the work week, and during the weekend. The mean hours expended per provider were calculated and compared between provider types and surgical specialty.ResultsMean time spent on EMR within working hours and after-hours during the work week was significantly less for surgeons than surgical APPs (1.76 hours/day vs. 2.10 hours/day, p<0.0001; 0.272 hours/day vs. 0.299 hours/day, p = 0.0173, respectively). Orthopedic surgery providers spent the most time logged into EMRs during working hours (2.33 hours/day), while neurosurgery expended the least time (1.42 hours/day). A high volume of encounters occurred within and outside working hours for all providers.ConclusionsRegardless of provider type or surgical specialty, substantial time was still universally expended navigating EMRs. This single institution study suggests that opportunities to optimize utility of EMR should be further explored to improve provider work-life balance.