军队远程医疗会诊环节规范化管理研究

目的：探讨军队远程医疗会诊规范化管理。方法：收集和检查了上海85医院远程会诊中心执行会诊的病历质量，并建立病案系统。结果：会诊中心4年共执行远程医疗会诊658例；其中传送会诊病历599例(91％)，影像图像392例(60％)，会诊意见单595例(90％)，采集了会诊实况录像203例(31％)。病历质量分析显示，58％的远程病历能被认可，1794幅放射影像图像中只有80％的影像图像被认为可阅读。结论：远程医疗会诊的最佳操作是远程病历应该预先传送，传输的病史应该完整，图像应该可阅读；为确保远程医学网络数据传递安全性和保密性，应采用专网专用的会诊软件；会诊资料收集多媒体化，病案标识和分类标准化，以及会诊病例管理信息化是远程医疗会诊规范操作的三个基本环节。

Standardization Management in Military Teleconsultation Process

Objective: To discuss links of standardization management in military teleconsultation. Methods: The author collected the medical records from telemedicine cases dealt with by the telemedicine center in No.85 military hospital and examined their quality. Results: There were 658 telemedicine cases in total. The medical records included the patient record in 599 cases (90.03%), transmitted images in 392 cases (59.57%), the consultant's opinion in 595 cases (90.43%) and video recording of the teleconsultation in 203 cases (30.85%). The quality of patient records was reviewed and found to be acceptable in 57.76% of cases. In total, 1794 radiology images (85% of all images) were transmitted via the telemedicine Network. The consultant considered 352 of them (20%) to be unreadable on the screen (i.e. 80% of radiology images were consider to be acceptable). Conclusion: For optimum performance of telemedicine, the patient record and associated images should be delivered in advance and the relevant parts of the record should be available during a teleconsultation. It is necessary to use the special software for telemedicine network and three aspects of the management of the medical records for teleconsultation: multimedia collection, standardization of patient' record identification and classification, and informational management.