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电子病案管理系统的实施与应用 总被引:3,自引:0,他引:3
指出传统病案管理模式存在的问题,从新旧病案归档整理、电子病案的使用等方面介绍电子病案管理系统的实施,阐明实施电子病案管理的意义,包括节省存储空间,提高检索效率、病案质量与规范管理等。 相似文献
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为更好的实现电子病案系统建设和效果评价,提出医院电子病案系统建设的主要功能应包括病历编辑修改功能、用户授权功能、模板管理功能、信息检索功能等,并应具有信息安全保障和法律效力。电子病案系统效果评价的主要指标是有利于提高工作效率、有利于提高医疗质量、有利于医疗资源共享。虽然主要问题电子签名还没有解决,但电子病案系统作为现代化的智能手段辅助医院的医疗工作是发展方向。 相似文献
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The security and privacy are important issues for electronic patient records (EPRs). The goal of EPRs is sharing the patients’ medical histories such as the diagnosis records, reports and diagnosis image files among hospitals by the Internet. So the security issue for the integrated EPR information system is essential. That is, to ensure the information during transmission through by the Internet is secure and private. The group password-based authenticated key agreement (GPAKE) allows a group of users like doctors, nurses and patients to establish a common session key by using password authentication. Then the group of users can securely communicate by using this session key. Many approaches about GAPKE employ the public key infrastructure (PKI) in order to have higher security. However, it not only increases users’ overheads and requires keeping an extra equipment for storing long-term secret keys, but also requires maintaining the public key system. This investigation presents a simple group password-based authenticated key agreement (SGPAKE) protocol for the integrated EPR information system. The proposed SGPAKE protocol does not require using the server or users’ public keys. Each user only remembers his weak password shared with a trusted server, and then can obtain a common session key. Then all users can securely communicate by using this session key. The proposed SGPAKE protocol not only provides users with convince, but also has higher security. 相似文献
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Pollettini JT Panico SR Daneluzzi JC Tinós R Baranauskas JA Macedo AA 《Journal of medical systems》2012,36(6):3861-3874
Surveillance Levels (SLs) are categories for medical patients (used in Brazil) that represent different types of medical recommendations. SLs are defined according to risk factors and the medical and developmental history of patients. Each SL is associated with specific educational and clinical measures. The objective of the present paper was to verify computer-aided, automatic assignment of SLs. The present paper proposes a computer-aided approach for automatic recommendation of SLs. The approach is based on the classification of information from patient electronic records. For this purpose, a software architecture composed of three layers was developed. The architecture is formed by a classification layer that includes a linguistic module and machine learning classification modules. The classification layer allows for the use of different classification methods, including the use of preprocessed, normalized language data drawn from the linguistic module. We report the verification and validation of the software architecture in a Brazilian pediatric healthcare institution. The results indicate that selection of attributes can have a great effect on the performance of the system. Nonetheless, our automatic recommendation of surveillance level can still benefit from improvements in processing procedures when the linguistic module is applied prior to classification. Results from our efforts can be applied to different types of medical systems. The results of systems supported by the framework presented in this paper may be used by healthcare and governmental institutions to improve healthcare services in terms of establishing preventive measures and alerting authorities about the possibility of an epidemic. 相似文献
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Obesity is a chronic disease with an increasing impact on the world’s population. In this work, we present a method of identifying obesity automatically using text mining techniques and information related to body weight measures and obesity comorbidities. We used a dataset of 3015 de-identified medical records that contain labels for two classification problems. The first classification problem distinguishes between obesity, overweight, normal weight, and underweight. The second classification problem differentiates between obesity types: super obesity, morbid obesity, severe obesity and moderate obesity. We used a Bag of Words approach to represent the records together with unigram and bigram representations of the features. We implemented two approaches: a hierarchical method and a nonhierarchical one. We used Support Vector Machine and Naïve Bayes together with ten-fold cross validation to evaluate and compare performances. Our results indicate that the hierarchical approach does not work as well as the nonhierarchical one. In general, our results show that Support Vector Machine obtains better performances than Naïve Bayes for both classification problems. We also observed that bigram representation improves performance compared with unigram representation. 相似文献
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通过以门诊电子病历为核心的门诊医生站实践,论述纸质门诊病历的缺点以及门诊电子病历的优势,总结在推行门诊电子病历过程中的重点和难点。同时指出在实施过程中应注意和其他信息系统的集成、数据标准化、完善管理制度、集成会诊系统等问题。 相似文献
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目前电子病历(EMR)在我国大型综合性医院应用比较广泛,但在中医院应用甚少。医院于2011年率先在江西省开发与应用了中医电子病历系统,填补了省内空白。对电子病历的开发与应用情况进行了探讨,并对应用过程中存在的问题提出相应的解决方案,以供参考。 相似文献
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目的:加强病历质控,提高病历质量,保障医疗安全。方法有效运用电子病历质控系统,对在院病历进行系统检查、环节实时分级控制、持续质量改进,对出院病历进行终末控制。结果病历及时性提高,雷同率降低,医院病历质量明显提高。结论利用电子病历质控系统,病历质量得到持续改进,病历完整性、正确性有了明显提高,保证病案医疗、教学、科研等服务水平。 相似文献
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Marion C.J. Biermans Geert H. Elbers Robert A. Verheij Willem Jan van der Veen Gerhard A. Zielhuis Pieter F. de Vries Robbé 《J Am Med Inform Assoc》2008,15(6):770-775
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To externally validate EPICON, a computerized system for grouping diagnoses from EMRs in general practice into episodes of care. These episodes can be used for estimating morbidity rates.Design
Comparative observational study.Measurements
Morbidity rates from an independent dataset, based on episode-oriented EMRs, were used as the gold standard. The EMRs in this dataset contained diagnoses which were manually grouped by GPs. The authors ungrouped these diagnoses and regrouped them automatically into episodes using EPICON. The authors then used these episodes to estimate morbidity rates that were compared to the gold standard. The differences between the two sets of morbidity rates were calculated and the authors analyzed large as well as structural differences to establish possible causes.Results
In general, the morbidity rates based on EPICON deviate only slightly from the gold standard. Out of 675 diagnoses, 36 (5%) were considered to be deviating diagnoses. The deviating diagnoses showed differences for two main reasons: “differences in rules between the two methods of episode construction” and “inadequate performance of EPICON.”Conclusion
The EPICON system performs well for the large majority of the morbidity rates. We can therefore conclude that EPICON is useful for grouping episodes to estimate morbidity rates using EMRs from general practices. Morbidity rates of diseases with a broad range of symptoms should, however, be interpreted cautiously. 相似文献18.
《中国数字医学》编辑部 《中国数字医学》2007,2(3):1
近年来,电子病历不仅是医院信息化建设中的难点和热点问题,也是人们议论和关注的焦点问题。什么是电子病历?其基本概念、功能结构、研发动态等,都是人们热情关注和迫切希望了解的。为此,本刊记者专门采访了解放军总医院计算机中心主任、高级工程师薛万国。薛主任是国内较早开展电子病历研究者之一,作为课题负责 相似文献
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Virginia L. Hinrichsen Benjamin Kruskal Megan A. O’Brien Tracy A. Lieu Richard Platt Vaccine Safety Datalink Team 《J Am Med Inform Assoc》2007,14(6):731-735
We implemented an automated vaccine adverse event surveillance and reporting system based in an ambulatory electronic medical record to improve underreporting and incomplete reporting that prevails in spontaneous systems. This automated system flags potential vaccine adverse events for the clinician when a diagnosis is entered, prompts clinicians to consider the vaccine as a cause of the condition, and facilitates reporting of suspected adverse events to the Vaccine Adverse Event Reporting System (VAERS).During five months, a total of 33,420 vaccinations were administered during 14,466 encounters. There were 5,914 follow-up contacts by vaccinees within 14 days of the vaccination visits; 686 (11.6%) generated an alert. Clinicians submitted VAERS reports for 23 of these (0.69 per 1,000 vaccine doses), which is almost 6 times the dose-based reporting rate to VAERS. 1 Clinician surveys indicated that it took a minimal amount of time to respond to the alerts. Of those who felt that an alert corresponded to an actual vaccine adverse event, the majority used the reporting feature to file a VAERS report.We believe that elicited surveillance via real time prompts to clinicians holds substantial promise. By coupling simplified reporting with the initial prompt, clinicians can consider and report a vaccine adverse event electronically in a few moments during the office visit. 相似文献