电子病历在随访及科研中的应用

复旦大学附属肿瘤医院利用电子病历系统。为每个门诊和住院病人建立统一标识，病人历次就诊和住院的电子病历均被关联该标识。实现了病人随访信息的自动登记。并建立科研病史。通过结构化病历实现了科研信息的收集与检索。     

Electronic Hand-Drafting and Picture Management System

The Department of Health of Executive Yuan in Taiwan (R.O.C.) is implementing a five-stage project entitled Electronic Medical Record (EMR) converting all health records from written to electronic form. Traditionally, physicians record patients’ symptoms, related examinations, and suggested treatments on paper medical records. Currently when implementing the EMR, all text files and image files in the Hospital Information System (HIS) and Picture Archiving and Communication Systems (PACS) are kept separate. The current medical system environment is unable to combine text files, hand-drafted files, and photographs in the same system, so it is difficult to support physicians with the recording of medical data. Furthermore, in surgical and other related departments, physicians need immediate access to medical records in order to understand the details of a patient’s condition. In order to address these problems, the Department of Health has implemented an EMR project, with the primary goal of building an electronic hand-drafting and picture management system (HDP system) that can be used by medical personnel to record medical information in a convenient way. This system can simultaneously edit text files, hand-drafted files, and image files and then integrate these data into Portable Document Format (PDF) files. In addition, the output is designed to fit a variety of formats in order to meet various laws and regulations. By combining the HDP system with HIS and PACS, the applicability can be enhanced to fit various scenarios and can assist the medical industry in moving into the final phase of EMR.     

Use of Electronic Medical Records in Oman and Physician Satisfaction

The Electronic Medical Record (EMR) is a computerized record of clinical, demographic and management information. EMR is an enabling technology that allows physicians to utilize quality improvement processes in the practice of medicine. Oman is one of the Middle Eastern Countries that has implemented an integrated electronic hospital information system at government health care institutions. The system was first applied in primary health care centers and then implemented in hospitals. Survey research highlights factors that affect physician satisfaction and utilizing of this new technology in a hospital setting. Outcome survey data suggests areas for improvement. Specific concerns about patient confidentiality are discussed as well as quality improvement in patient care.     

基于电子病历系统关系数据库构建患者诊疗图谱

介绍在电子病历(Electronic Medical Record,EMR)系统中使用图数据库的目的,阐述使用Neo4j对EMR系统关系数据进行建模的全过程,构建某医院门诊患者就诊记录多关系异构诊疗知识图谱,实现EMR系统中关系数据库结构可视化,并探索利用图数据库来挖掘数据管理和分析的潜力。     

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。     

急救伤病信息快速采集分类系统设计开发

突发事件下急救信息的采集与分类具有十分重要的意义,急救信息采集分类系统能够有效提高伤员分类效率、降低伤员转移过程中的人为错误率,在信息上实现全医疗过程一体化管理,在物理上与后续医疗救治环节进行无缝衔接.以急救伤病信息采集分类系统中涉及的诸多技术为基础,研究急救过程中的各个关键环节,通过对实际急救场景的归纳分析,并结合现有纸质急救病历,整合使用现有信息化手段,设计开发了急救伤病信息采集分类系统,实现了提高伤员急救效率、增强急救过程医疗安全性、完成伤员急救信息与医院电子病历整合的目标.     

病案室如何做好电子病案管理

本文阐述了该院病案室做好电子病案管理的七个方面：(1)转变观念,主动适应；(2)探索有效管理办法以缩短实施电子病案的磨合期；(3)做好电子病案的指控工作；(4)完善电子病案的归档管理；(5)实施电子病案的分级保密管理；(6)做好电子病案的调用和交换管理；(7)积极推进建立基于数字签名认证中心(CA)的数字签名。     

基于HL7 CDA标准和XML技术在电子病历系统中的应用

在对电子病历系统互通性的分析基础上。简单论述了电子病历相关的HL7 CDA标准的主要内容、CDA标准与HL7 V3标准的相关性以及采用XML技术进行医疗文档描述的优点。最后介绍了CDA标准在电子病历系统中的应用举例。     

搜索处理技术在医院非结构化文档（电子病历）的应用

随着医院信息化的发展,电子病历（Electronic Medical Record, EMR）在当前受到越来越多的关注,尤其在各级医疗院所及其健康体检中心,然而在医生需要正确获取患者资料时,确是件费力的事。尤其是在海量信息进行患者模糊查询,效率非常低下,同时全结构化电子病历仍然达不到医生看病的日常状态,大部分医院仍在使用非结构化的电子病历系统或SOAP诊断模式,围绕文本信息检索和电子病历相结合,旨在为信息查询提供思维的速度。除此之外,搜索处理技术对影像文件也可以进行处理,达到快速定位影像。     

大港油田总医院临床合理用药管理体系构建

以合理用药监测系统（PASS）为基础和核心,利用医院管理信息系统（HIS）、电子病历（EMR）、实验室管理信息系统（LIS）等信息化手段,为临床合理用药工作提供有效的数据分析和支持服务,为医疗管理和决策提供客观依据,构成合理用药管理体系,提高用药的合理性。     

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.     

基于WPF的中医电子病历系统设计与实现

基于中医病历较西医病历的特殊性,基于WPF设计面向中医专业人员的电子病历系统。从数据库设计、WPF与MVVM模式、XAML与数据绑定、界面设计与自定义控件等方面,详细介绍系统的设计与实现,阐述系统的功能模块及数据挖掘,指出系统的创新之处。     

电子病案新技术临床应用前景

我国电子病案的发展处于初级阶段。电子病案的应用可以提高工作效率和医疗质量。随着电子计算机和数字化技术的迅猛发展,把新技术应用于电子病案,使电子病案智能化、高技术化和人性化成为可能。     

医生因素对医院实施电子病历系统的影响

目的：探索医生作为技术使用者对于医院建立电子病历系统的影响。方法：对～家北京市三甲医院实施电子病历系统的现状和效果进行个案研究,主要使用定性研究方法,以观察法和半结构访谈法作为主要资料收集方法。结果：尽管有了一个良好的技术设计,但是电子病历系统的信息采集、存储、处理和展现等功能并没有在该院发挥理想效果,医生对技术的接受和使用程度不足影响了电子病历系统发挥提升效率和质量的意义。结论：行政权威要求不足、培训不到位、短期效率降低、感知易用性不足等是医生使用系统的主要障碍因素。     

基于电子病历大数据的人工智能医疗质量与安全实时监控云平台研究

阐述基于电子病历大数据的人工智能医疗质量与安全实时监控云平台系统架构设计、应用情况,评估系统建设效能,指出该平台对促进建立以电子病历系统为核心的医疗质控系统具有实践意义。     

门诊电子病历系统在医院中的应用

随着《电子病历系统功能规范》和《电子病历系统功能应用水平分级评价方法及标准》等规范的发布,越来越多的医院使用了电子病历系统,但大部分医院只局限于使用住院电子病历,门诊电子病历还在沿用手写的传统模式。基于门诊电子病历系统在某三甲医院上线的过程为背景,介绍了门诊电子病历特点,以及门诊电子病历帮助门诊医生解决的模板病历书写等一些实际问题。最后对新一代门诊电子病历系统提出一些新颖的病历自动形成等功能点,门诊电子病历的应用需要尽量符合门诊医生思维习惯,贴近门诊医生看诊过程,起到对门诊医生的辅助指导作用,为门诊电子病历系统的建设和应用提供指导。     

Transaction-Neutral Implanted Data Collection Interface as EMR Driver: A Model for Emerging Distributed Medical Technologies

Electronic Medical Record (EMR) and Electronic Health Record (EHR) adoption continues to lag across the US. Cost, inconsistent formats, and concerns about control of patient information are among the most common reasons for non-adoption in physician practice settings. The emergence of wearable and implanted mobile technologies, employed in distributed environments, promises a fundamentally different information infrastructure, which could serve to minimize existing adoption resistance. Proposed here is one technology model for overcoming adoption inconsistency and high organization-specific implementation costs, using seamless, patient controlled data collection. While the conceptual applications employed in this technology set are provided by way of illustration, they may also serve as a transformative model for emerging EMR/EHR requirements.     

对医疗数据为医院管理与临床诊疗提供支持的研究

医院信息系统（HIS）提供了海量医疗数据,有效利用这些数据可以为医疗管理决策与临床科研提供数量化的依据.从统计学角度,提出提高电子病历（EMR）数据采集质量的建议,介绍了针对医院信息数据分析的数据挖掘方法,有助于医疗工作者与管理人员更好地发现医院数据中蕴藏的信息.     

电子病案在医疗领域中的应用

电子病案(Electronic Medical Record,EMR)是一项提高医疗质量和效率,降低医疗成本的医疗变革。它建立在医院医疗活动全面信息化的基础上,能提供主动的、智能化服务。它是用电子设备保存、管理、传输和重现的数字的病人的医疗记录,它包含了传统纸张病案的所有信息,也反映了患者的整个医疗过程。随着医疗信息及网络技术的发展,国内大医院已开始积极进行电子病案的研究。“军卫一号”工程的运用,加速了医院的现代化、信息化建设的步伐。我院是开展EMR较早的医院之一。电子病案具有传输速度快、存储量大、方便快捷等特点。电子病案扩大了医院的管理领域,变终未为环节,为国家和军队医疗宏伟管理提供了原始科学的数据信息资源。有效发挥病案在医、教、研方面的真正价值和作用。它对医院的内部管理、国家医疗保障、病人信息的异地共享也具有重要的意义。它是信息技术和网络技术在医疗领域的必然产物