电子病历的管理与利用

以中山市人民医院为例,介绍将电子病历从在线系统中离线导出,生成独立的病历文档包、存储和调阅的过程和方法,包括报告单虚拟打印、纸质病历数字化扫描、病历分级存储等方面,实现电子病历长期、安全存储和访问管理.     

电子病案管理系统的实施与应用

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。     

电子病案系统的建设与效果评价

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。     

Utilization of Electronic Medical Records to Build a Detection Model for Surveillance of Healthcare-Associated Urinary Tract Infections

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.     

绩效考核对电子病历首页质量控制的影响

为探讨绩效考核对电子病历首页质控的作用,随机抽取河北省人民医院2014年1-3月及2014年4-6月的电子病历首页各3 600份,统计并比较两个时间段病案首页错误填写发生率,结果发现实行绩效考核后病案首页7项基本信息及7项医疗信息填写错误率均下降,且具有统计学意义。     

Using Machine Learning Classifiers to Assist Healthcare-Related Decisions: Classification of Electronic Patient Records

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.     

Extracting Information from Electronic Medical Records to Identify the Obesity Status of a Patient Based on Comorbidities and Bodyweight Measures

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.     

纸质病历电子化方案研究与设计

为将历史纸质病历转化成可分析、可检索的电子病历,并与现有电子病历系统进行整合,实现各大医院历史纸质病历在科研、管理、卫生监控等方面发挥重要作用,研究设计了纸质病历电子化系统。通过人工录入与机器结合的方式,将纸质病历转化成电子数据,并与现有电子病历系统进行整合,实现纸质病历信息的数据化存储、分析、检索。为充分挖掘纸质病历中信息的科研价值做出重要贡献。     

推行门诊电子病历的实践与思考

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。     

中医电子病历系统的开发与应用

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。     

电子病历质量监控系统的功能与应用

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。     

甲型HIN1流感电子病历与手写病历规范化比较

目的比较我院点选式电子病历与手写病历在甲型H1N1流感住院患者临床应用中的规范性差别。方法选我院甲型H1N1流感住院患者手写病历117份、电子病历127份。对甲型H1N1流感常见症状如发热、咳嗽等进行统计,分析两者病案规范性差别。结果电子病历与手写病历在症状、体征的描述记录上有显著性差异。结论点选式电子病历较传统手写病历对甲型H1N1流感住院患者病史收集记录更加全面、规范。医生应加强规范化收集病史的意识。     

真实世界电子病历数据评价研究综述

从评价主体、应用场景、评价内容、评价方法4方面对真实世界电子病历数据评价研究进行综述并提出对未来的展望,以期为进一步探索电子病历数据科学评价体系提供参考.     

电子病案应用对教学医院的影响

本文以电子病案及教学医院为切入点,以医学生及医护人员为中心,探讨教学医院实施电子病案的必要性、现状及对医学生及医患双方的优点及不足。提出在教学医院实施电子病案应以双轨制为过渡态,最终完全实施电子病案,这样有利于提高医学生及医护人员的规范化意识,提高教学医院的教学质量,更好地为医学院校及社会各方服务。     

市级医院电子病历应用水平分级评价的研究与评估

依据国家相关标准,结合上海市级医院电子病历系统建设的实际情况,上海申康医院发展中心建立市级医院电子病历应用水平分级评价体系模型,研发评估系统产品,组织评估系统应用示范,完成对34家市级医院电子病历系统应用水平的等级评估,积极推进及提高各市级医院电子病历建设水平,引导市级医院科学合理的发展电子病历系统。     

External Validation of EPICON: A Grouping System for Estimating Morbidity Rates Using Electronic Medical Records

Objective

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.     

电子病历:医院信息化建设的核心

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     

患者代理人病案复印申请材料审核情况调查

目的调查患者代理人病案复印申请材料的相关情况,探讨政策制定和减轻医院复印人员工作压力的方法。方法对北京地区28所三级医院审核患者代理人病案复印申请材料的相关情况进行调查。结果各医院对申请材料的内容、如何留存、特殊情况处置方式不同。近5年共发生3起因审核不严而导致的投诉。结论医院应采取切实可行的方式,提前告知复印病案所需材料,使患者授权符合要求。同时制度也应具体可行,使大多数人做得到。     

Using Electronic Medical Records to Enhance Detection and Reporting of Vaccine Adverse Events

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.