以“军卫一号”系统为基础的一体化医疗平台建设的几点体会

按照总后卫生部的统一部署,＂十二五＂期间将在全军范围内推广＂浙大中控新版电子病历系统＂。新版电子病历系统在医护一体化工作站集成、电子病历数据查询,以及医疗数据综合展示方面具有特色,     

新型的数据库网络电子病历系统简介

电子病历作为医院计算机网络管理的一个重要内容，应该充分体现计算机网络的程序化、自动化和规范化，使计算机优势尽可能得到最大限度的发挥，以真正地达到减轻临床医生工作量之目的。为了弥补医院信息系统（简称HIS）中电子病历存在的不足，我院开发研制了新型的数据库网络电子病历系统，该系统在电子病历技术发展方面进行了许多有益的尝试。本文着重叙述了该系统在临床应用中的特点以及在医院管理方面的优势。     

精准医学的临床部署：顶层架构设计及关键信息技术

随着世界范围内研究者对多维度信息融合分析投入越来越多的关注,精准医学成为一种全新的医学模式。精准医学的核心是通过多维度信息分析患者的个体差异以达到精准预防、精准治疗的目的。精准医学的优势在于借助新的生物学技术及信息技术,将基因组信息整合入临床实践,提供临床决策支持,以实现对疾病的发病机制、分型等进行全新的探索和诠释。精准医学的关键技术包括疾病亚型分组技术、临床决策支持系统、电子病历的改版升级、伦理学挑战及知情同意管理、术语控制与本体开发及全表型组关联分析技术等。作者旨在结合全球范围内精准医学取得的进展对中国精准医学临床部署进行规划,以提高疾病的治愈率,改善患者的预后及生活质量,提升国民健康水平。     

军队数字化卫勤建设系列讲座（1） 军队数字化医院建设总体构想

关于数字化医院的概念,国外是在普遍运用医院管理信息系统、临床信息系统、电子病历系统基础上,于20世纪90年代提出的;国内是2002年10月在全国卫生信息化会议上提出的。数字化医院（包括数字化疗养院）,是指在信息采集、处理、存储、获取、再现和分析决策中,普遍采用IT技术,将其用于医、教、研、管的全过程,包括体征获取与监控,生化、影像、诊断、治疗、手术等临床诊治的各个环节与流程,使数字医学技术在医院得到充分、全面、有效的应用。同时,数字化医院建设还是一个动态的、发展的过程。     

医疗维权与电子病历的质量管理

病历是客观记录医疗活动过程的重要资料,不仅反映医疗质量和学术水平,还是医疗维权举证不可或缺的证据.制约电子病历推广和普及的原因之一,是电子病历是否具备法律效力.判定电子病历在发生医疗争执中法律责任的举证能力,又是论证电子病历法律地位的关键问题[1].作者对我院实行电子病历以来存在的潜在法律责任问题进行了分析,为提高电子病历质量,使其更具法律效力,结合临床实际工作,从病历的统一标准规范、修改、监管等方面,对软件设计方案提出了对策.     

解剖图片在电子病历中的应用

“军字一号”在军队医院的广泛应用,一改过去手工书写病历字迹潦草的现象,电子病历变得书面整洁、格式规范,但病历中文字表述欠准确的现象仍时有发生。手写病历时,外科医学常将图章印在病历上,用于标识肿物、损伤及手术位置等,以达到直观、准确描述的作用。我科运用“军字一号”电子病历系统时,考虑到图章标识的直观性,将本科常需描述解剖部位制成简易图片存入电脑内,形成电子病历时在相应位置将图片插入,标注肿物、损伤及手术位置,以完成图章作用。目前,我科已经完成插入解剖图片的病历达150余份,该操作简单易行,省时省力,每次操作只需30~5…     

住院电子病历首页常见缺陷分析

随着信息技术的不断进步,医院信息系统(HIS)的大规模应用已成为医疗改革的必然趋势[1]。我院自1999年开始建设HIS系统,经历了以收费为中心的管理模式向以临床为中心的服务模式的重大转变。电子病历(EMR)作为临床信息系统的核心,在医疗质量和医疗安全管理中发挥着不可替代的重要作用,而病历     

标准化电子病历在电子化临床路径中的应用现状

在深化医药卫生体制改革的背景下,卫生部和国家中医药管理局为推进以医院管理和电子病历为重点的医院信息化建设,2009年底发布了《电子病历基本架构与数据标准(试行)》[1]。该标准将临床路径(clinical pathway,CP)列为临床文档标准数据组之一,奠定了临床数据的标准化基础,使电子病历产生的结构化、标准化数据作为执行临床路径的依据,实现临床路径电子化信息化管理成为可能。该标准的发布     

电子病历的特点分析及对策建议

1 电子病历的优势 1．1 信息量大 电子病历系统提供了超越纸质病历的功能。电子病历系统的信息整合，从形式上将不同系统的信息整合成“以患者为中心”的信息系统，从内容上将患者的各类诊疗信息集成，从时间上将患者历次门诊、住院诊疗信息按时间序列集成。可以快速查看高清晰图像并提供测量、调整图像功能；医技系统可使临床医师看到与检查医师同样的B超、内镜图像；药物知识库提供药品相互作用、配伍禁忌、药物剂量控制，可最大限度防止用药差错，并且促进了合理用药。     

电子病历研究的几点思考

近年来,电子病历研究已成为国内外医院信息化建设和讨论的热点问题.笔者从电子病历的主要特点分析,指出电子病历实现需要长期的发展过程,只有建立在完善的临床信息系统之上的电子病历才是严格意义上的电子病历.     

From PACS to integrated EMR.

The integration of medical images as part of the patient record has always been a critical component of documentation and information supporting clinical decisions. In the past two decades the increased number of imaging procedures that allows a more accurate and more specific diagnosis has significantly increased and their role in patient management has grown rapidly. With the evolution toward digital modalities and management of medical images in a fully digital environment with the deployment of enterprise wide Picture Archiving Communication Systems (PACS) a wider and more rapid access to the images by referring physicians and clinicians has become possible. The parallel evolution of electronic medical records (EMR) supporting all other documents and clinical data in electronic format led to the necessity of integrating medial image data with the rest of the patient record. Although the marriage of medical images and patient record data in electronic format seems a very natural and necessary combination it has often been very slow in development due to the lack of standardization and clear understanding of clinical workflows and clinical requirements. Several early implementations demonstrated the added value of combining medical images with the patient record and have shown that the availability of data and images facilitates and improves the accuracy and efficiency of patient management. Recent efforts in industry and the academic community to harmonize and improve the integration of medical images with patient record, with the promotion of new standards and better definitions of clinical workflows and standard mechanism of integration of different types of data into unified data models, has facilitated the deployment of modern EMR. Also, a shift in paradigm due to recent technological revolutions such as the development of the World Wide Web and the concepts of portal servers for accessing data for multiple sources has significantly boosted the trends into open systems which allows easier and more functional integration of medical data from different sources. Furthermore, the emergence of a new strategy for software development, based on open source components, allows software programs to be shared and exchanged between different institutions leading to more rapid deployment of standardized electronic patient record.     

Redesigning the nuclear medicine reading room

The process of image review and interpretation has become increasingly complex and challenging for today's nuclear medicine physician from many perspectives, especially with regard to workstation integration and reading room ergonomics. With the recent proliferation of hybrid imaging systems, this complexity has increased rapidly, along with the number of studies performed. At the same time, clinicians throughout the health care enterprise are expecting remote access to nuclear medicine images whereas nuclear medicine physicians require reliable access at the point of care to the electronic medical record and to medical images from radiology and cardiology. The authors discuss the background and challenges related to integration of nuclear medicine into the health care enterprise and provide a series of recommendations for advancing successful integration efforts. Also addressed are unique characteristics of the nuclear medicine environment as well as ergonomic, lighting, and environmental considerations in the design and redesign of the modern reading room.     

Role of the battalion surgeon in the Iraq and Afghanistan War

The battalion surgeon is an invaluable asset to a deploying unit. The primary role of a battalion surgeon is to provide basic primary care medicine and combat resuscitation. Other expectations include health care screening, vaccinations, supervision of medics, and being a medical advisor to the unit's commander. As many physicians who fill this role previously worked at medical treatment facilities or medical centers without prior deployment experience, the objective of this article is to highlight some of the challenges a battalion surgeon may encounter before, during, and following deployment.     

机动医院信息系统的设计

目的对机动医院信息系统进行组网设计和优化。方法通过对医院信息系统组网分析,结合机动医院特点,组建适合快速展开、安全的通信网络。结果组建机动医院信息网络,应用于战时机动医院信息系统,完成电子伤票、实验室信息系统（LIS）、图像存档与通讯系统（PACS）、放射学信息系统（RIS）、远程会诊等功能。结论设计一套适合机动医院信息系统组网方案,将提高我军机动医院信息化水平。     

Quality of deployment surveillance data in southwest Asia.

The Global Expeditionary Medical System (GEMS), formerly known as Desert Care II, provides clinical data on every medical encounter that occurs at U.S. Air Force medical treatment facilities in theater. After 22 months of surveillance from March 1997 to January 1999, 59,026 records were generated from 27,305 active duty members. A random sample of 273 individuals were reviewed for four key fields: chief complaint, diagnosis, International Classification of Diseases, 9th Revision, code, and disease and nonbattle injury category. The vast majority (> 99%) of records were consistently classified and reported. An unrelated subset of all cases categorized as "Medical/Other" seen at Prince Sultan Air Base (5,640 records) also were analyzed. Reassignment was made in 19% of cases into other categories, suggesting that further refinement of disease and nonbattle injury reporting is needed for effective deployment medical surveillance. Overall, this electronic data-gathering system has high internal validity, consistency, and reliability for service members in the deployed U.S. Air Force setting.     

Development of electronic medical recording system for clinics using the internet based on patient participation in pursuit of NBM

The current medical system does not allow sufficient time for medical interviews, a situation that can create problems in patient-doctor relationships and result in a variety of problems. The importance of narrative based medicine (NBM) has been raised as a result of the overemphasis on evidence based medicine (EBM) in recent years. From this point of view, we have developed an electronic medical recording (EMR) system for clinics that uses the Internet and is based on patient participation, in pursuit of NBM. This system enables the patient to report information prior to the face-to-face interview with his or her doctor. In this way, the patient has more time to summarize and explain physical conditions and concerns. These reports from patients are automatically saved to the EMR database, without any additional workload. Therefore, this system will provide more effective communication between patient and doctor. In addition, the doctor is able to receive the results of medical treatment directly, in addition to the patient's other records. These sets of records will contribute to more efficient operation of the clinic. At this time, we have improved this system on the assumption that outsourcing the server will avoid the burden of maintenance. This prototype system uses a personal identification number (PIN) and an encode/decode algorithm for security. The secure PIN enables us to use conventional e-mail. Through experimental clinical testing, the effects on mutual understanding in medical examinations were studied. We are confident that this system based on patient narratives will contribute greatly to the spread of EMR systems for clinics operated by family physicians.     

Ethics in sports medicine

Physicians have struggled with the medical ramifications of athletic competition since ancient Greece, where rational medicine and organized athletics originated. Historically, the relationship between sport and medicine was adversarial because of conflicts between health and sport. However, modern sports medicine has emerged with the goal of improving performance and preventing injury, and the concept of the "team physician" has become an integral part of athletic culture. With this distinction come unique ethical challenges because the customary ethical norms for most forms of clinical practice, such as confidentiality and patient autonomy, cannot be translated easily into sports medicine. The particular areas of medical ethics that present unique challenges in sports medicine are informed consent, third parties, advertising, confidentiality, drug use, and innovative technology. Unfortunately, there is no widely accepted code of sports medicine ethics that adequately addresses these issues.     

The integration of medical images with the electronic patient record and their web-based distribution

Medical images are currently created digitally and stored in the radiology department's picture archiving and communication system. Reports are usually stored in the electronic patient record of other information systems, such as the radiology information system (RIS) and the hospital information system (HIS). But high-quality services can only be provided if electronic patient record data is integrated with digital images in picture archiving and communication systems. Clinicians should be able to access both systems' data in an integrated and consistent way as part of their regular working environment, whether HIS or RIS. Also, this system should allow for teleconferencing with other users, eg, for consultation with a specialist in the radiology department. This article describes a web-based solution that integrates the digital images of picture archiving and communication systems with electronic patient record/HIS/RIS data and has built-in teleconferencing functionality. This integration has been successfully tested using three different commercial RIS and HIS products.