社区卫生信息标准化中的编码研究

社区医疗基本数据集的标准研究是卫生信息标准化的主要研究任务之一。信息标准是社区卫生服务迅速发展、社区卫生服务信息规范管理、信息交换与信息共享的前提。以社区医疗基本数据集的标准化研究为出发点,依据信息分类和编码的基本原则与方法（中华人民共和国国家标准GB/T7027—2002）,针对《社区居民健康档案（试用）》中档案编码技术的不足,对社区卫生服务中的档案编码标准化进行深入研究,并给出具体的编码方案。     

医疗术语编码方案与可交换信息结构绑定方法探讨

探讨医疗术语编码方案与可交换信息结构绑定的一种方法。通过将卫生部颁布的基本医疗数据集（BDS）中的相关数据元与HL7 v3 CDA R2体系结构相结合，实现用一种特定的方式捕获、显示临床医疗数据，以标准化、无歧义的数据格式处理临床描述。     

社区中心（站）与三级医院双向转诊情况分析

目的分析社区中心（站）与三级医院的双向转诊现状。方法回顾分析。结果2005年8月～2006年3月，社区站共有107人参加双向转诊，其中向中心病房转诊91例次（90．09％），向三级医院转诊16例次（9．91％），中心病房向社区站转诊75例次。中心病房向三级医院转诊10例次。转诊主要病种：慢性支气管炎／肺气肿／肺部感染、高血压、冠心病、糖尿病等慢性病。结论社区站与中心双向转诊方便、快捷。缓解了居民“看病难，住院难”问题，特别是解决了低收入群众的基本医疗服务，有利于对社区慢性病人连续性健康管理。     

住院病案首页信息的共享与标准化

目的探讨病案首页的信息共享与标准化方法。方法根据《国家卫生信息标准基础框架》与《国家卫生数据字典》,通过扩展标记语言(XML)Schema对病案首页的文档结构与具体元素分别进行定义。结果定义了病案首页信息的Schema文档,将首页信息划分为患者的基本信息、临床信息和费用信息3部分,定义文档结构;首页中每一个数据项映射到《国家卫生数据字典》中对应的数据元,定义元素的属性;根据确定的XML Schema文档形成了XML Schema图。结论XML技术与数据元知识相结合,为病案首页信息在不同信息系统间的共享提供了一个可行的标准化方法。     

基于IHE XDS／XCA的跨区域医疗信息共享交换系统设计

该系统是在遵循IHE XDS．b（Cross-enterprise documentsharing）和IHE XCA（Cross-Community Access）技术规范基础上,采用SOA（Service Oriented Architecture）和EDA（Event Driving Architecture）技术架构及网格概念。设计和开发的一种跨区域（Cross-Community）医疗信息共享交换（EHR）系统。系统由四个层次组件组成：一个市级注册中心（XDSRegistry）;多个区级域XDS注册中心,每一个对应相应的行政管理域;与域级注册中心相对应的多个文档存储池（XDS Repository）;以及提供病人基本信息的文档源代理（XDS Source Actor Agents）。通过对该系统进行海量医疗文档数据发布、用户查询和图像提取等操作进行的压力测试和评估结果表明。该EHR系统可用于中、大城市多区域、多医疗机构之间的医疗信息共享交换和医疗协同。     

面向互认共享的医学影像结果报告结构化模板的构建

在分析梳理面向共享的医学影像结果报告业务流程的基础上,借鉴HL7 CDA R2架构,基于我国卫生信息共享文档编制规范,构建了医学影像结果报告的结构化模板,并与卫生信息数据元目录进行了映射。其中文档头包括主题数据和管理数据,文档体分为临床信息、成像设备信息及过程描述、检查结果信息3个章节及若干条目。     

全科医疗转诊体系框架研究

全科医疗转诊是分级诊疗制度的重要组成部分,高质量的转诊体系是患者获得连续、协调、整合性医疗服务的基础。发展建立一个全面的转诊体系分析框架,有助于研究者和政策制定者全面思考转诊体系的要素及要素间关系,指导实践者建立和完善转诊体系。本研究广泛吸收国外转诊研究成果,运用系统论方法,构建了全科医疗转诊体系框架,明确了其中的4个核心要素（转诊参与者及其责任、转诊决策、转诊信息的传递与整合、转诊管理系统）,并阐述了各要素的内涵。从而提出对我国今后开展转诊研究的3点建议：（1）应重视和发挥转诊单的医疗功能;（2）制定转诊指南;（3）重视转诊体系的管理属性,开展转诊管理系统的探索。     

基于健康档案的社区卫生信息系统研究与应用

探讨电子健康档案的建设标准,建设基于标准化电子健康档案（Electric Health Record,EHR）的区域协同医疗信息网络,研究建立基于电子病历与健康档案的区域协同医疗服务新模式,在区域内三级医院和社区卫生服务机构之间实现预约挂号、双向转诊、远程会诊、代理检验、急诊绿色通道等信息化医疗服务,大力优化区域医疗卫生资源配置。实现区域医疗卫生保健信息资源共享。     

医院-社区脑出血患者双向转诊标准及干预方法的探讨

探讨三级医院与社区卫生服务中心之间脑出血患者的双向转诊的标准和干预方案。2007年10月至2010年9月我们采用医院与社区协商制定脑出血术后患者的双向转诊标准进行双向转诊。共91例患者,失访13例。其中干预组42例,采用双向转诊标准,对照组36例,患者、家属自行选择转诊,随访3年。干预组患者遵医服药（95％,40例）、生活自理能力Barthel指数提高（50％,21例）、身体功能障碍Fugl—Meyer运动功能量表评分提高（79％,33例）、自我监测（81％,34例）及定期复查（76％,32例）的比例均高于对照组,对照组依次为64％（23例）、31％（11例）、28％（10例）、25％（9例）、25％（9例）（均P〈0．01）,且对照组平均每人费用为2246元／月,干预组为575元／月。三级医院向社区转诊的标准及干预方法有利于脑出血术后患者康复及降低医疗费用。     

英国初级卫生保健转诊系统对我国分级诊疗及基层医疗信息化建设的借鉴

英国国家医疗服务体系包括初级卫生保健系统和医院系统,转诊推荐信是全科医生和专科医生间沟通的方式,其中包含的信息对于转诊质量和效率有提高的作用。研究转诊推荐信的信息有助于为我国的分级诊疗提供建议。本文通过检索有关组织机构制定的指南、规范,系统评价有关文献,得出主要关注指标,形成政策分析及建议。结果发现转诊推荐信的质量控制体系主要由英国国家卫生及医疗优化研究院制定的转诊指南、临床调试集团制定的关键绩效指标构成。英格兰地区在转诊选择、转诊期望、转诊时间、诊断等方面还有改善空间,但是患者对于现在的转诊基本满意。提示提高转诊质量需要做到规范转诊医疗行为,充分提升信息化在转诊中的作用,建立全科医生和专科医生之间的密切关系,引入非卫生技术人员作为全科医生助理等。     

Building Clinical Data Groups for Electronic Medical Record in China

This article aims at building clinical data groups for Electronic Medical Records (EMR) in China. These data groups can be reused as basic information units in building the medical sheets of Electronic Medical Record Systems (EMRS) and serve as part of its implementation guideline. The results were based on medical sheets, the forms that are used in hospitals, which were collected from hospitals. To categorize the information in these sheets into data groups, we adopted the Health Level 7 Clinical Document Architecture Release 2 Model (HL7 CDA R2 Model). The regulations and legal documents concerning health informatics and related standards in China were implemented. A set of 75 data groups with 452 data elements was created. These data elements were atomic items that comprised the data groups. Medical sheet items contained clinical records information and could be described by standard data elements that exist in current health document protocols. These data groups match different units of the CDA model. Twelve data groups with 87 standardized data elements described EMR headers, and 63 data groups with 405 standardized data elements constituted the body. The later 63 data groups in fact formed the sections of the model. The data groups had two levels. Those at the first level contained both the second level data groups and the standardized data elements. The data groups were basically reusable information units that served as guidelines for building EMRS and that were used to rebuild a medical sheet and serve as templates for the clinical records. As a pilot study of health information standards in China, the development of EMR data groups combined international standards with Chinese national regulations and standards, and this was the most critical part of the research. The original medical sheets from hospitals contain first hand medical information, and some of their items reveal the data types characteristic of the Chinese socialist national health system. It is possible and critical to localize and stabilize the adopted international health standards through abstracting and categorizing those items for future sharing and for the implementation of EMRS in China.     

Medical Markup Language (MML) for XML-based Hospital Information Interchange

Medical Markup Language (MML) has been developed over the last 6 years in order to create a set of standards by which medical data, within Japan and hopefully worldwide, can be stored, accessed and exchanged in any number of physical locates. The MML version 2.21 is characterized by XML as meta-language, module structure for each document and enhancement of linking function among documents. Data exchange specification has been also added for query and reply. MML instances are composed of MML header and MML body. The MML header includes information for data transmission, while MML body includes several module items. One module item contains two elements: document information and module content. Nine MML module contents are defined at the present time: patient information, health insurance information, diagnosis information, lifestyle information, basic clinic information, particular information at the time of first visit, progress course information, surgery record information and clinical summary information.     

基于医院集成平台的区域医疗交换CDA设计与实现

为实现标准化的区域医疗信息数据交换,以医院集成平台为核心,在现有医院各类信息系统基础上,按照标准的医疗CDA文档格式,将医院各类信息资源集成起来,构建符合区域卫生信息平台技术规范的CDA文档,实现与常熟市区域卫生信息平台数据交换。     

医学观察数据的元数据框架反标准化应用

目的：构建医学观察数据的语义模型和元数据框架,为医学观察数据的规范化表达和信息共享提供基础.方法：参照国际标准化组织ISO有关信息技术标准及SNOMED CT、LOINC等医学领域相关国际、国家标准,定义医学观察项目的属性和元数据规范,采用UML建模.结果：医学观察数据的语义模型将医学观察逐步分解,形成类的树状层次结构.第一层可分为体格检查、实验室检查等4个子类;类包含一组特定的属性;属性以数据元的形式,通过元数据进行描述;一组特定属性（数据元）的实例即为规范化的医学观察数据.结论：语义模型和元数据框架规范下的医学观察数据具有完整、清晰的语义和统一的格式.构建元数据框架有利于医学观察数据的标准化,可作为国家卫生数据字典的研发策略.     

基于CDA双向转诊信息交互的研究与实现

新医改推动各地卫生部门对区域卫生平台建设的探索,双向转诊因其在促进患者有效诊疗下沉和区域卫生资源合理流动方面的巨大作用,成为区域卫生平台中的重要衔接环。分析了双向转诊业务和流程,抽象出双向转诊信息模型,确定双向转诊的活动列表、数据集以及数据集的数据元在信息模型中的位置和表达方式;通过构建与解析基于HL7标准的双向转诊信息、共享基于HL7CDA标准的双向转诊摘要等技术,为实现基于区域平台的双向转诊业务提供可行性方案。     

An Electronic Health Record Based on Structured Narrative

Objective

To develop an electronic health record that facilitates rapid capture of detailed narrative observations from clinicians, with partial structuring of narrative information for integration and reuse.

Design

We propose a design in which unstructured text and coded data are fused into a single model called structured narrative. Each major clinical event (e.g., encounter or procedure) is represented as a document that is marked up to identify gross structure (sections, fields, paragraphs, lists) as well as fine structure within sentences (concepts, modifiers, relationships). Marked up items are associated with standardized codes that enable linkage to other events, as well as efficient reuse of information, which can speed up data entry by clinicians. Natural language processing is used to identify fine structure, which can reduce the need for form-based entry.

Validation

The model is validated through an example of use by a clinician, with discussion of relevant aspects of the user interface, data structures and processing rules.

Discussion

The proposed model represents all patient information as documents with standardized gross structure (templates). Clinicians enter their data as free text, which is coded by natural language processing in real time making it immediately usable for other computation, such as alerts or critiques. In addition, the narrative data annotates and augments structured data with temporal relations, severity and degree modifiers, causal connections, clinical explanations and rationale.

Conclusion

Structured narrative has potential to facilitate capture of data directly from clinicians by allowing freedom of expression, giving immediate feedback, supporting reuse of clinical information and structuring data for subsequent processing, such as quality assurance and clinical research.     

护理文书全程监控的质量分析

目的构建精神科护理文书全程监控的管理模式,保障护理文件书写质量,为患者提供优质护理服务。方法将2009-2010年487份出院病历分为对照组及全程监控组,对存在缺陷进行分析。结果实施全程监控后,与对照组相比,护理记录中的缺陷频数减少了54项,两组的共性问题缺陷频数减少了57项,同时增强护理人员的法律证据意识及慎独精神,提升业务能力及素养,提高全员参与的主动性、积极性,提高护理记录水平。结论全程监控能有效提高护理文书的书写质量,促使护士规范医疗行为的养成,起到有效预防医疗纠纷的作用。     

Emergency Healthcare Process Automation Using Mobile Computing and Cloud Services

Emergency care is basically concerned with the provision of pre-hospital and in-hospital medical and/or paramedical services and it typically involves a wide variety of interdependent and distributed activities that can be interconnected to form emergency care processes within and between Emergency Medical Service (EMS) agencies and hospitals. Hence, in developing an information system for emergency care processes, it is essential to support individual process activities and to satisfy collaboration and coordination needs by providing readily access to patient and operational information regardless of location and time. Filling this information gap by enabling the provision of the right information, to the right people, at the right time fosters new challenges, including the specification of a common information format, the interoperability among heterogeneous institutional information systems or the development of new, ubiquitous trans-institutional systems. This paper is concerned with the development of an integrated computer support to emergency care processes by evolving and cross-linking institutional healthcare systems. To this end, an integrated EMS cloud-based architecture has been developed that allows authorized users to access emergency case information in standardized document form, as proposed by the Integrating the Healthcare Enterprise (IHE) profile, uses the Organization for the Advancement of Structured Information Standards (OASIS) standard Emergency Data Exchange Language (EDXL) Hospital Availability Exchange (HAVE) for exchanging operational data with hospitals and incorporates an intelligent module that supports triaging and selecting the most appropriate ambulances and hospitals for each case.     

单病种引导信息化支撑的区域性医疗资源纵向整合探索

为发挥区域内各级医院有效资源,使病员得到优质、便捷的医疗服务,进一步利用已经建设的区域医疗信息共享系统,开发了以单病种为纽带,信息系统为支撑的肿瘤诊疗业务临床协同系统。系统以规范的单病种诊疗指南为基础,整合区域内医疗信息数据,建立及时优质的分级医疗和规范、连贯性的转诊医疗服务流程及动态医疗信息共享。在不改变当前体制机制的情况下,探索出在区域居民健康档案网络平台上,充分利用信息资源,开展慢病按病种诊疗协同服务的新模式,为医改要求的实施区域性医疗资源整合提供新途径。     

CLAIM (CLinical Accounting InforMation)—An XML-Based Data Exchange Standard for Connecting Electronic Medical Record Systems to Patient Accounting Systems

With the evolving and diverse electronic medical record (EMR) systems, there appears to be an ever greater need to link EMR systems and patient accounting systems with a standardized data exchange format. To this end, the CLinical Accounting InforMation (CLAIM) data exchange standard was developed. CLAIM is subordinate to the Medical Markup Language (MML) standard, which allows the exchange of medical data among different medical institutions. CLAIM uses eXtensible Markup Language (XML) as a meta-language. The current version, 2.1, inherited the basic structure of MML 2.x and contains two modules including information related to registration, appointment, procedure and charging. CLAIM 2.1 was implemented successfully in Japan in 2001. Consequently, it was confirmed that CLAIM could be used as an effective data exchange format between EMR systems and patient accounting systems.