数字医院模式下电子病历的无纸化存储

我院自2007年6月开始推行电子病历无纸化存储以来,其显示出巨大优势,给临床工作带来了极大方便,减轻了临床医生的工作负担,且利于确保病历书写的规范标准化,提高医疗质量,同时明显降低医疗费用.但在应用中也存在一些问题.因此,采取对策,如加强培训,进行电子病历认证,加强督查,强调手工签名,保证法律效力,加强保密工作,保护病人隐私等.     

病历、电子病历与中医电子病历

本文从中医病历的历史演化，西医病历的发展过程出发，对中西医病历的特点进行了分析，并对电子病历及中医电子病历作了一些简单的介绍。     

电子病历面临的问题和思考

传统病历电子化的过程面临以下八个问题：①我国无电子病历的统一标准，使得信息难以整合与交换；②电子病历未得到法律上的认可，使其很难有序发展；③保静陛存在较大漏洞；④存储空间小，难以满足病历反复使用的特点；⑤电子病历质量存在许多问题；⑥医护之间的脱节现象；⑦电子病历管理制度不完善增大了病案管理难度；⑧系统软硬件的配置问题。就以上问题，本文提出了如下解决办法：①制定我国电子病历管理办法；②建立电子病历的标准；③尽快立法，得到法律保障；④采取措施提高电子病历的安全性；⑤建立、健全质量监督控制机制；⑥培养提高医护人员素质。     

电子病历初探

电子病历即电子化的医疗记录(electronic medical record,EMR),本文对电子病历的定义、优点,及电子病历存在的问题进行了探讨.     

从电子病历系统到区域电子病历系统建设与发展

本文从当前电子病历系统的建设及应用情况出发，阐述了其发展方向即区域电子病历及市民健康信息系统，并对市民健康信息系统的建设环境、技术架构和主要内容进行了探讨。     

浅析制约电子病历发展的主要问题

电子病历(Computer-based Patient Record．简称CPR)是病历未来发展的方向，但目前存在着法律地位的确立、规范标准的制定、可行技术的应用等主要问题。要解决法律、标准、技术问题，必须进行积极的探索研究，同时也需要得到全社会的关注，尽快制定、实施、开发相应的法律、标准和技术，推动电子病历的健康发展。     

网络时代的电子病历

随着医疗保健体制的改革和网络技术的发展,电子病历的应用日益迫切,本文讲述了电子病历的概念、现状、关键因素和发展前景。提出了网络化电子病历的发展方向。     

试论电子病历

电子病历作为临床信息系统的核心而成为ＨＩＳ开发中一个极为重要的研究课题。本文对它的定义、应具有的功能、给予医疗的意义及影响、以及我国开发需解决的某些问题作了尝试性探讨     

关于医院实施电子病历系统的若干认识与思考

近年来,随着医院信息化建设的不断深入和发展,电子病历系统已经成为有关部门和业界人士共同关注的热点.电子病历之所以受到前所未有的关注和重视,是因为它是临床信息系统研发和应用的核心,是医院信息化建设向纵深发展的关键,是开展区域医疗卫生信息化的起点,也是满足国民健康服务信息需求的源头.目前,全世界范围内已形成共识:病历电子化不推进.就会直接影响医院信息系统的开发和使用.     

电子病历系统应用的实际意义

电子病历作为医院数字化的核心,已成为医院、医疗主管部门关注的热点问题.通过实施电子病历,提升了医院管理质量,提高了医院竞争力.无论是对病人的医疗保健还是医院、行业乃至社会都有十分重要的意义,同时在实施中也存在着一些问题.     

带血管腓骨干切取应用解剖的几点补充

目的:为临床带血管腓骨干切取补充解剖学基础。方法:在24侧防腐固定的成年小腿标本上,将腓骨全长平均分为4段,解剖观测腓骨肌肉的附着及部分肌肉的神经支配情况,观测腓骨营养血管的起始位置的特征。结果:腓骨干上附着肌肉的宽度从大到小依次为腓骨肌面、屈肌面、胫骨后肌面和伸肌面。腓骨短肌的肌支发出处距腓骨头尖(9.9±2.7)cm,于腓骨中2/4段和中3/4段的上半部分最贴近腓骨骨面,长伸肌的第1肌支起始位置距腓骨头尖(10.1±1.9)cm,于腓骨的中2/4段紧贴腓骨前缘,腓骨滋养动脉和第1￣3弓状动脉集中于腓骨中2/4段。结论:(1)带血管腓骨干所可能切取的“肌袖”主要为长屈肌和胫骨后肌;(2)腓骨肌面的中2/4段和中3/4段的上半部分为手术时容易损伤腓骨短肌肌支的部位;(3)腓骨中2/4段近腓骨前缘是长伸肌神经支最易损伤的部位;(4)近端截骨点位于腓骨上1/4段中点的切取可以最大程度地包含腓骨的营养血管。     

Computer-assisted expert case definition in electronic health records

PurposeTo describe how computer-assisted presentation of case data can lead experts to infer machine-implementable rules for case definition in electronic health records. As an illustration the technique has been applied to obtain a definition of acute liver dysfunction (ALD) in persons with inflammatory bowel disease (IBD).MethodsThe technique consists of repeatedly sampling new batches of case candidates from an enriched pool of persons meeting presumed minimal inclusion criteria, classifying the candidates by a machine-implementable candidate rule and by a human expert, and then updating the rule so that it captures new distinctions introduced by the expert. Iteration continues until an update results in an acceptably small number of changes to form a final case definition.ResultsThe technique was applied to structured data and terms derived by natural language processing from text records in 29,336 adults with IBD. Over three rounds the technique led to rules with increasing predictive value, as the experts identified exceptions, and increasing sensitivity, as the experts identified missing inclusion criteria. In the final rule inclusion and exclusion terms were often keyed to an ALD onset date. When compared against clinical review in an independent test round, the derived final case definition had a sensitivity of 92% and a positive predictive value of 79%.ConclusionAn iterative technique of machine-supported expert review can yield a case definition that accommodates available data, incorporates pre-existing medical knowledge, is transparent and is open to continuous improvement. The expert updates to rules may be informative in themselves. In this limited setting, the final case definition for ALD performed better than previous, published attempts using expert definitions.     

Confidentiality,privacy, and security of genetic and genomic test information in electronic health records: points to consider

As clinical genetics evolves, and we embark down the path toward more personalized and effective health care, the amount, detail, and complexity of genetic/genomic test information within the electronic health record will increase. This information should be appropriately protected to secure the trust of patients and to support interoperable electronic health information exchange. This article discusses characteristics of genetic/genomic test information, including predictive capability, immutability, and uniqueness, which should be considered when developing policies about information protection. Issues related to “genetic exceptionalism”; i.e., whether genetic/genomic test information should be treated differently from other medical information for purposes of data access and permissible use, are also considered. These discussions can help guide policy that will facilitate the biological and clinical resource development to support the introduction of this information into health care.     

A multi-technique approach to bridge electronic case report form design and data standard adoption

Background and objectiveThe importance of data standards when integrating clinical research data has been recognized. The common data element (CDE) is a consensus-based data element for data harmonization and sharing between clinical researchers, it can support data standards adoption and mapping. However, the lack of a suitable methodology has become a barrier to data standard adoption. Our aim was to demonstrate an approach that allowed clinical researchers to design electronic case report forms (eCRFs) that complied with the data standard.MethodsWe used a multi-technique approach, including information retrieval, natural language processing and an ontology-based knowledgebase to facilitate data standard adoption using the eCRF design. The approach took research questions as query texts with the aim of retrieving and associating relevant CDEs with the research questions.ResultsThe approach was implemented using a CDE-based eCRF builder, which was evaluated using CDE- related questions from CRFs used in the Parkinson Disease Biomarker Program, as well as CDE-unrelated questions from a technique support website. Our approach had a precision of 0.84, a recall of 0.80, a F-measure of 0.82 and an error of 0.31. Using the 303 testing CDE-related questions, our approach responded and provided suggested CDEs for 88.8% (269/303) of the study questions with a 90.3% accuracy (243/269). The reason for any missed and failed responses was also analyzed.ConclusionThis study demonstrates an approach that helps to cross the barrier that inhibits data standard adoption in eCRF building and our evaluation reveals the approach has satisfactory performance. Our CDE-based form builder provides an alternative perspective regarding data standard compliant eCRF design.     

Female sexual dysfunction: the important points to remember

Media exposure regarding male sexual dysfunction and the growing number of viable treatment alternatives for erectile dysfunction has resulted in increasing numbers of men seeking clinical appointments and treatment for the condition, which has previously been considered taboo. Because these problems usually arise within the context of relationships, some investigators have alluded to increased rates of sexual dysfunction among the partners of these men. Also, since general practitioners, gynaecologists, geriatrists, and urologists are also seeing female patients for evaluation of various types of dysfunction, certain groups of these women with underlying chronic conditions have been noted to have high rates of concomitant sexual dysfunction. Physicians who have good rapport with these patients are in a privileged position to help with these intimate problems, which are often difficult for patients to discuss. Therefore, it is of extreme importance that these professionals become knowledgeable about and comfortable with the initial evaluation and possible treatment of female sexual dysfunction.