湖北省医疗机构病案信息化建设现状调查

目的了解湖北省医疗机构病案信息化建设现状及存在的问题。方法通过全国医疗质量数据抽样调查专栏,对湖北省二级以上综合医院病案科进行网络调查,获得2018年医疗机构病案科电子病历和签名技术使用、病案贮存、病案质控和病案信息安全等方面情况。结果116家医疗机构均使用电子病历系统;但使用电子病历归档技术的占56.03%,全部病案使用CA签名的仅占7.76%,病案手工签字占65.52%;纸质贮存病案占到69.83%,开展病案终末形式质控的机构占比最高,为91.38%,采用信息化手段开展住院病案首页质控比例最高,占45.26%;长期贮存全部影像医疗记录的有75家,占64.66%,没有脱敏流程就导出病案信息的机构占34.48%。结论电子病历系统应用广泛,但电子病历归档技术和病案无纸化应用有待推广;病案质控仍以传统的人工质控开展为主,信息化质控手段使用有限;仍有部分医院病案信息无法以影像的方式长期存贮,病案信息利用上存在安全隐患。

Investigation on the Status Quo of Medical Record Information Construction in Hubei Province

Objective To explore the basic situation and problems of medical record information construction in Hubei Province.Methods Through the national medical quality data sampling survey column,a network survey was conducted on the medical record departments of general hospitals at or above the second level in Hubei Province.the use of electronic medical records and signature technology,medical record storage,medical record quality control and medical record information security were obtained in 2018.Results The electronic medical record system was used by all 116 medical institutions,however,56.03%of them use electronic medical record filing technology,only 7.76%use CA signatures for all medical record.65.52%of them sign medical records manually while paper storage medical records account for 69.83%.The highest quality control at the end of the medical record accounting for 91.38%.The highest proportion of medical record through information means was first-page accounted for 45.26%.Long-term storage of all imaging medical records accounted for 64.66%.Using the data without desensitization in the process accounted for 34.48%.Conclusion The electronic medical record system is widely used,but the electronic medical record filing technology and the paperless application of medical records need to be promoted;The medical records is still mainly carried out by traditional manual quality control and the use of information-based quality control methods is limited;Some hospital cannot store the medical record information forever and the use of medical record information has potential safety hazards.