利用医院信息系统推动临床药学发展

随着医院药学由传统药品供应保障型向临床药学技术服务型的转变，医院信息系统(HIS)对临床药学的支持作用日趋重要。基于HIS实现电子药历临床信息的自动生成，操作简便，提供的信息全面、准确；构建抗生素合理应用自动监控系统，对抗生素的多项指标实行自动监控。HIS在临床药学的功能拓展，为临床药学服务提供了良好的工作平台，提高了工作效率，提升了药学服务水平，有助于临床药学和HIS的进一步发展。     

拓展医院信息系统功能提升药学服务和管理水平

以病人为中心，服务于临床为宗旨，拓展医院信息系统(HIS)在病区药房的功能。利用HIS自动生成并打印符合临床要求的摆药标签，实现病区药房调剂无纸化，不仅能减少差错，还提高了工作效率和服务质量；利用HIS实现药历的自动生成，临床资料自动读入，生成药历操作简便，提供的信息全面、及时，为药学服务提供了良好的应用平台；建立了工作人员考核和管理的量化体系，提高了工作效率和管理水平。     

电子病案开发应用中几个问题的探讨

医院信息系统 (HIS)从 2 0世纪 80年代开始在我国普及发展 ,目前部分医院已开发出适合本医院的信息系统并在网上运行〔1〕。国外有一些卫生机构将HIS划为二种 :一种是早期的以管理信息和费用管理为主信息流的医院管理信息系统 (HospitalManagementInformationSystem ,HMIS) ;第二种是以病人为主信息流的临床信息系统 (ClinicInformationSystem ,CIS)。今后HIS发展的趋势将转向CIS的开发和利用。临床信息系统包括电子病历 (CPR)、图像传输 (PACS) ,实验室检查和仪器传输系统以及远程医疗等人机交换系统 ,它是用于临床信息管理…     

HIS中病案统计"外挂件"的应用

20世纪90年代初我国医疗卫生领域开始推行信息化建设,条件好一些的大医院相继建立起医院信息管理系统(Hospital Information System),有一些还建立了检验或放射信息系统,近期文献还有关于医保、电子药历信息系统的报道,但文献中对病案统计信息管理系统报道较少.实际工作中病案统计信息在HIS中占有非常重要的位置[1],因为病案统计系统直接面对的是数据的采集和录入,是关乎HIS数据库建设的关键.     

长沙市哨点医院流感样病例监测模式效果评价

目的 评估电子信息系统在哨点医院流感样病例监测中的运行效果,探讨流感样病例监测新模式.方法 在长沙市两家哨点医院中的一家医院(长沙市中心医院)中采用电子信息系统收集监测门诊信息和流感样病例(ILI)信息,在另一家医院(长沙市第一医院)中继续实行手工登记方式收集相关信息.从“中国流感监测信息系统”中导出2010年第6周-2015年第5周两家医院的ILI监测数据进行统计分析.结果 手工登记时期与HIS过渡时期两家哨点医院ILI％差值的差异没有统计学意义,手工报表时期与HIS正式运行时期两家哨点医院ILI％差值的差异有统计学意义,HIS过渡时期与HIS正式运行时期ILI％差值的差异有统计学意义.结论 HIS操作简单,数据客观,利用HIS收集和报告ILI信息的方式必将逐渐取代传统的手工报告方式,成为一种新的流感样病例监测模式.     

医院无线临床信息系统架构及实现

无线临床信息系统是目前医院信息化建设的一个热点领域。医院的HIS、LIS、PACS等信息还散落在各个不同的系统中,临床对于以病人为中心,统一病人相关临床数据的要求日益迫切。无线临床信息系统是医院电子病历发展应用的必然阶段,它能极大程度的解决医护信息共享问题,使临床医护人员更贴近病患,能及时在床边处理医嘱。本文将以本院建设的成功案例为蓝本,着重介绍医院各个信息系统与电子病历集成的无线临床信息系统的架构。     

我院HIS/PACS软件集成方案的设计和应用

做好医院信息系统（HIS）与医学影像与传输系统（PACS）整合,增强医院各信息系统之间的信息交互,提高工作效率,是PACS应用成功与否的关键。本文阐述了我院HIS与PACS集成后具备的典型操作流程,介绍了以中间表方式实现了HIS与PACS的集成,该集成方法开发效率高、简单。集成后的系统运行稳定,得到了临床医生的一致好评。     

医院信息系统的目标与实施策略

一、医院信息系统的概念 医院信息系统(简称HIS)是现代化医院运营的必要技术支撑和基础设施,是集计算机、网络、通讯等高科技技术,为医院各部门提供病人医疗信息、病人费用信息、行政管理信息和决策分析信息的收集、处理、加工和分析的计算机应用软件系统。HIS系统不仅改变了目前信息的收集与处理方式,同时带来管理模式的变革。 二、医院信息系统的三个主要部分 我们认为,医院信息系统针对不同的服务对象与功能分为三个部分:(1)基于医院经济管理与医疗管理的医院管理信息系统,简称HIS。(2)服务于临床医疗教学科研的医学影像     

构建服务医疗管理的医院统计信息平台的设想

为探讨在医院信息系统(简称“HIS”)环境下如何作好医疗管理工作的信息保障,文章阐述了军队医院基于医院信息系统构建统计信息平台的解决方案,为医院科学化管理和决策提供依据。     

医院感染监测预警分析系统与HIS接口的设计与实现

目的：通过医院信息系统与感染监测预警分析系统的互联,实现与HIS的全面接轨,对信息资料实施自动采集、储存和统计功能,实现医院感染网络化监控和管理.方法：根据国家相关法规及医院感染管理工作的经验,采用SQL Server数据库、PB开发平台与HIS全面整合的网络版信息化系统进行设计.结果：实现了信息的采集、储存与传输应用手段的自动化及信息综合分类与加工处理方式的集约化.结论：该系统使医院感染信息系统操作简单,监测准确、及时,覆盖面广,为医院感染的控制与预防提供了可靠的依据.     

手术室移动护理信息平台的开发与应用

目的基于电子病历系统应用水平分级评价标准,开发以PAD为载体的手术室移动护理信息平台并应用到临床。方法根据手术护理工作内容,围绕患者360、手术转运、术中用药、术中输血、物品清点、三方核查、风险评估、术前访视和术后随访等流程,开发手术室PAD移动护理信息平台。 结果平台应用后,实现了医院不同系统间信息数据的互联共享,集成了手术护理工作的各项内容。手术转运、安全核查、物品清点等的记录合格率均有所提升（P<0.05）。结论手术室移动护理信息平台的应用满足了手术护理工作需要,提高了手术室信息化水平。     

基于HIS的心电网络信息系统研究实施

目的：研究一种基于HIS的心电网络信息系统，更好地方便医生和患者，完善患者的电子病历，提升信息化水平。方法：医院在较高的信息化水平和良好的网络应用环境中，经过研究论证，结合医院自身特点，成功实施了心电信息综合管理系统。结果：该系统健全了电子病历，取得了良好的应用效果。结论：基于HIS实施心电网络信息系统应用效果好，成果明显，值得推广。     

电子病案管理规范研究

电子病案与纸张病案相比,在形成方式、存储过程和使用方法上都发性了极大的变化。因此,必须建立一套科学的、完整的、严谨的管理规范。而且这一规范需要逐步形成行政的法规,否则,电子病案就不能顺利进入实用。本文就电子病案质量管理规范;电子病案管理质量规范;电子病案使用管理规范等方面做了方面做一探讨。     

Accurate case finding using linked electronic clinical and administrative data at a children's hospital

To link hospital administrative data and an electronic medical record at a children's hospital in order to identify children with cancer admitted for fever and neutropenia. Hospital administrative data concerning 13,374 inpatient and outpatient encounters were validated against and linked to clinical data stored in an electronic medical record. Queries of the linked databases identified children with fever and neutropenia. Sensitivity and specificity of the experimental case-finding strategy were determined and compared to a control case-finding strategy utilizing administrative data alone. Linking of the clinical record to the administrative record was achieved in 233 (99%) of the 235 records. Of 1680 data elements reviewed from the administrative data that were also potentially available in the clinical data system, 1679 (99.9%) were verified in the electronic medical record. The experimental strategy for case finding had a sensitivity of 73.1% (95% CI: 58.1, 88.3), specificity 99.6% (95% CI: 99.1, 100). If only administrative data such as diagnosis-related group and hospital service were used for case finding, both the sensitivity (P < 0.01) and specificity (P < 0.01) were significantly lower. Linking a children's hospital administrative data system with clinical data is feasible and can be utilized for specific case finding for a common and costly condition in children.     

A systematic review of computer-based patient record systems and quality of care: more randomized clinical trials or a broader approach?

PURPOSE: To analyse the impact of computer-based patient record systems (CBPRS) on medical practice, quality of care, and user and patient satisfaction. DATA SOURCES: Manual and electronic search of the Medline, Cochrane, and Embase databases. STUDY SELECTION: Selected articles were published from 2000 to March 2003. CBPRS was defined as computer software designed to be used by clinicians as a direct aid in clinical decision making. To be included, the systems should have recorded patient characteristics and offered online advice, or information or reminders specific to clinicians during the consultation. DATA EXTRACTION: Keywords used for the search were: electronic record, informatic record, electronic medical record, electronic patient record, patient order entry, computer-based patient system, clinical decision support systems, and evaluation. RESULTS: Twenty-six articles were selected. Use of a CBPRS was perceived favourably by physicians, with studies of satisfaction being mainly positive. A positive impact of CBPRS on preventive care was observed in all three studies where this criterion was examined. The 12 studies evaluating the impact on medical practice and guidelines compliance showed that positive experiences were as frequent as experiences showing no benefit. None of the six studies analysing the impact of CBPRS on patient outcomes reported any benefit. CONCLUSIONS: CBPRS increased user and patient satisfaction, which might lead to significant improvements in medical care practices. However, the studies on the impact of CBPRS on patient outcomes and quality of care were not conclusive. Alternative approaches considering social, cultural, and organizational factors may be needed to evaluate the usefulness of CBPRS.     

Factors influencing electronic clinical information exchange in small medical group practices

Purpose: The purpose of this study was to identify the organizational factors that influence electronic health information exchange (HIE) by medical group practices in rural areas. Methods: A purposive sample of 8 small medical group practices in 3 experimental HIE regions were interviewed to determine the extent of clinical information exchange with other health care providers and to identify the factors influencing those patterns. Findings: HIE was found to be largely limited to exchanging immunization data through the state health department and exchanging clinical information within owned provider systems. None of the clinics directly exchange clinical information with non‐owned clinics or hospitals. Conclusions: While regional HIE networks may be a laudable goal, progress is slow and significant technical, political, and financial obstacles remain. Limiting factors include data protection concerns, competition among providers, costs, and lack of compatible electronic health record (EHR) systems.     

Getting to Complete and Accurate Medication Lists During the Transition to Home Health Care

ObjectivesCharacterize the work that home health care (HHC) admission nurses complete as part of the medication reconciliation tasks, explore the impact of shared electronic medication data (interoperability) from the referral source on medication reconciliation, and highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.DesignObservational field study.Settings and ParticipantsThree diverse Pennsylvania HHC agencies; each used different electronic health record systems with different interoperability characteristics. Six nurses per site admitted 2 patients each (36 patients total).MethodsResearchers observed the admission process in the patient home and at the HHC agency. The nurses’ tasks related to medication reconciliation were characterized by (1) number and change types (ie, medications dropped or added; changes to dose, frequency/administration time, or tablet types) made to the referrer medication list during and after the home visit, and (2) reasons that the nurse called the health provider (doctor, pharmacy) to resolve medication-related issues. Differences between interoperable and non-interoperable observations were explored.ResultsPolypharmacy (on average, study patients were taking more than 12 medications) and high-risk medications (on average, more than 8 per patient) were pervasive. For 91% of patients, the number of medications decreased between pre- and post-reconciliation medication lists; 41% of the medications required changes. Nurses using interoperable systems needed to make fewer changes than nurses using non-interoperable systems. In two-thirds of observations, the nurse called a provider.Conclusions and ImplicationsChanges to the referrer medication list and calls to providers highlighted the nurses’ effort to complete the medication reconciliation. Interoperability appeared to reduce the number of changes required, but did not eliminate changes or calls to providers. We highlight opportunities to enhance medication reconciliation with respect to transition in care to HHC agencies.     

医院船电子病历系统构建方法探讨

目的：为医院船建立电子病历系统提供科学有效的解决方案。方法：结合项目对在医院船上构建电子病历系统的核心问题进行了分析,并从系统集成引擎、临床数据中心、临床应用和远程互联几个方面对架构的设计进行了分析、设计和探讨。结果：建立了医院船电子病历系统的体系结构。结论：建立的体系结构解决了建立医院船电子病历系统的核心问题,为进一步的研究指明了方向。