数字化病案在医用信息化建设中的作用与特征分析
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摘要
数字化病案作为数字化医院系统工程的重要组成部分,其发展与落实对医院病案管理的信息化建设起到巨大推动作用,可有效解决医院病案资料保存、大数据共享、信息安全和科研利用等多方面问题,能够为医务人员及相关部门提供更快捷、方便、高效和优质的信息服务。随着医院管理中数字化档案的发展与应用,存在的问题随之逐渐显现,为探索科学、高效的病案管理方法,及其在医院信息化建设中的发展趋势,分析数字化病案特征和发展现状,对其在医院信息化建设中的作用、价值及其特征进行评价,以期为数字化病案在医疗保险、教学、科研及医疗等方面更好地发挥作用提供理论依据。
The development and implementation of digital medical records that is important constituent of system engineering of digital hospital plays an enormous motivational effect in information construction of medical records management of hospital.And it is a good management method that can effectively solve series of problems included data preservation of medical records of hospital, big data sharing, information security, utilization of scientific research and so on. And it can provide more efficient, convenient, efficient, high-quality information services for medical staffs and relevant departments. Of course, some existing problems have gradually emerged with the development and application of digital archives in hospital management.In order to further explore scientific and efficient management methods of medical record, and to explore its development trend in information construction of hospital, this paper analyzes the characteristics and development status of digital medical record, and evaluates its effect, value and characteristic in informatization construction of hospital so as to provide theoretical basis for digital medical record that can better playrole in disputes, insurance, teaching, scientific research, medical treatment and so on of hospital.
The development and implementation of digital medical records that is important constituent of system engineering of digital hospital plays an enormous motivational effect in information construction of medical records management of hospital.And it is a good management method that can effectively solve series of problems included data preservation of medical records of hospital, big data sharing, information security, utilization of scientific research and so on. And it can provide more efficient, convenient, efficient, high-quality information services for medical staffs and relevant departments. Of course, some existing problems have gradually emerged with the development and application of digital archives in hospital management.In order to further explore scientific and efficient management methods of medical record, and to explore its development trend in information construction of hospital, this paper analyzes the characteristics and development status of digital medical record, and evaluates its effect, value and characteristic in informatization construction of hospital so as to provide theoretical basis for digital medical record that can better playrole in disputes, insurance, teaching, scientific research, medical treatment and so on of hospital.
引文
[1]王玲,刘文杰,亓天晓,等.病案数字化存在问题及解决方案探讨[J].中国病案,2014,15(7):9-11.
[2]Halfon P,Eggli Y,Decollogny A,et al.Disease identification based on ambulatory drugs dispensation and in-hospital ICD-10 diagnoses:a comparison[J].BMC Health Serv Res,2013(13):453.
[3]李书梅,张艳芬,徐小莉,等.数字化病案服务于医学科研的管理探讨[J].中华医学科研管理杂志,2013,26(1):58-59.
[4]刘堃靖,张红,李力.数字化病案统一信息服务平台的建立与应用[J].中国医疗设备,2016,31(9):104-106.
[5]杨霜英,周丽君,于京杰.基于缩微数码影像技术的数字化病案管理系统的研究[J].中国医学装备,2013,10(9):15-17.
[6]邱雪梅,盛瑞雯.浅谈细节管理在数字化翻拍病案中的作用[J].中国病案,2014,15(10):6-7.
[7]林鑫,许凤娟,李会玲.公立医院数字化病案管理实践探讨[J].中国医院管理,2015,35(11):64-65.
[8]Lim C,Theobald J,Patel H,et al.Benefits of radiation/nerve agent exposure electronic medical record order set construction[J].Clinical Toxicology,2014,52(7):791-792.
[9]袁萍,甄玲,袁晓露.新形势下病理档案资料的管理[J].中国病案,2013,14(12):6-7.
[10]陈丽.区域医疗环境下电子病案系统的应用与管理[J].中国病案,2017,18(7):46-49.
[11]洪雅君,王继伟,姜新莉.数字化归档病案的管理和利用[J].中国病案,2013,14(9):52-53.
[12]侯兆红,徐虹,顾欣,等.网络模式下病案信息利用及效果[J].中国病案,2014,15(8):5-6.
[13]陈小小,李扬眉,梁莹.浅谈病案数字化翻拍的现状[J].中国病案,2013,14(12):26-28.
[14]王莹,刘克新,郑琳.基于影像扫描技术的病案数字化质量管理[J].中国医院管理,2013,33(12):55-56.
[15]王均华,方孝梅,袁瑞良,等.浅析司法活动对病案管理发展的要求[J].中国病案,2013,14(8):48-49.
[16]曹阳,程红群,王晓阳,等.数字化影像病案信息系统的建立与应用[J].中国数字医学,2014,9(11):35-37.
[17]席姗姗.试论数字化病案室的构建及管理[J].中国急救医学,2016,36(z1):339-340.
[18]陈小琤,孙涛.谈纸质病案的数字化[J].中国病案,2013,14(12):28-29.
[19]贺乐平.以电子病历为核心的数字化医院建设[J].计算机与现代化,2013(2):157-158.
[20]Jeong CW,Lee SG,Lee J,et al.Construction of Dynamic Medical Information System for Digital Hospital Environments[J].Wireless Personal Co mmunications,2016,91(4):1575-1590.
[21]孟凡婷,马慧,孙巍.医院病案数字化管理与建设探讨[J].西北国防医学杂志,2013(3):298-300.
[22]杨凌燕.病案信息化过程中质量监控及风险防范[J].现代仪器与医疗,2013,19(5):8-11.
[23]李力.数字化技术在病案管理中的应用[J].医疗卫生装备,2013,34(10):47-48.
[24]张帧,商建国,李汉民.基于翻拍技术和条形码技术的病案数字化应用研究[J].中国数字医学,2014,9(10):101-103.
[25]刘洋,王弥,邱恺.基于病案数字化的病案复印流程再造效果评价[J].中国病案,2014,15(4):36-38.
[26]Lee DH,Hong KS,Kim NY.Effects of hospital leadership,organizational systems,and ESWOSon medical error reduction[J].Service Business,2014,10(1):1-19.
[27]范晓棠.数字化病案管理应用效果分析[J].中国病案,2017,18(6):1-3.
[28]赖丽文,王逸纯,赵淑媛.现代化信息技术在病案管理中的应用[J].中国病案,2014,15(4):34-36.
[29]樊美娜,王凯鹏,葛佳.谈病案数字化扫描服务器存储扩容[J].中国病案,2014,15(12):31-32.
[30]刘建花,栾红.病案数字化的应用效果[J].中国病案,2014,15(10):8-9.
[31]李迎新,陈能太.电子签名在医院电子病历中的实施[J].中国医学装备,2018,15(04):94-97.
[32]张明.历史纸质病案数字化工作实践探讨[J].东南国防医药,2014,16(3):327-328.
[2]Halfon P,Eggli Y,Decollogny A,et al.Disease identification based on ambulatory drugs dispensation and in-hospital ICD-10 diagnoses:a comparison[J].BMC Health Serv Res,2013(13):453.
[3]李书梅,张艳芬,徐小莉,等.数字化病案服务于医学科研的管理探讨[J].中华医学科研管理杂志,2013,26(1):58-59.
[4]刘堃靖,张红,李力.数字化病案统一信息服务平台的建立与应用[J].中国医疗设备,2016,31(9):104-106.
[5]杨霜英,周丽君,于京杰.基于缩微数码影像技术的数字化病案管理系统的研究[J].中国医学装备,2013,10(9):15-17.
[6]邱雪梅,盛瑞雯.浅谈细节管理在数字化翻拍病案中的作用[J].中国病案,2014,15(10):6-7.
[7]林鑫,许凤娟,李会玲.公立医院数字化病案管理实践探讨[J].中国医院管理,2015,35(11):64-65.
[8]Lim C,Theobald J,Patel H,et al.Benefits of radiation/nerve agent exposure electronic medical record order set construction[J].Clinical Toxicology,2014,52(7):791-792.
[9]袁萍,甄玲,袁晓露.新形势下病理档案资料的管理[J].中国病案,2013,14(12):6-7.
[10]陈丽.区域医疗环境下电子病案系统的应用与管理[J].中国病案,2017,18(7):46-49.
[11]洪雅君,王继伟,姜新莉.数字化归档病案的管理和利用[J].中国病案,2013,14(9):52-53.
[12]侯兆红,徐虹,顾欣,等.网络模式下病案信息利用及效果[J].中国病案,2014,15(8):5-6.
[13]陈小小,李扬眉,梁莹.浅谈病案数字化翻拍的现状[J].中国病案,2013,14(12):26-28.
[14]王莹,刘克新,郑琳.基于影像扫描技术的病案数字化质量管理[J].中国医院管理,2013,33(12):55-56.
[15]王均华,方孝梅,袁瑞良,等.浅析司法活动对病案管理发展的要求[J].中国病案,2013,14(8):48-49.
[16]曹阳,程红群,王晓阳,等.数字化影像病案信息系统的建立与应用[J].中国数字医学,2014,9(11):35-37.
[17]席姗姗.试论数字化病案室的构建及管理[J].中国急救医学,2016,36(z1):339-340.
[18]陈小琤,孙涛.谈纸质病案的数字化[J].中国病案,2013,14(12):28-29.
[19]贺乐平.以电子病历为核心的数字化医院建设[J].计算机与现代化,2013(2):157-158.
[20]Jeong CW,Lee SG,Lee J,et al.Construction of Dynamic Medical Information System for Digital Hospital Environments[J].Wireless Personal Co mmunications,2016,91(4):1575-1590.
[21]孟凡婷,马慧,孙巍.医院病案数字化管理与建设探讨[J].西北国防医学杂志,2013(3):298-300.
[22]杨凌燕.病案信息化过程中质量监控及风险防范[J].现代仪器与医疗,2013,19(5):8-11.
[23]李力.数字化技术在病案管理中的应用[J].医疗卫生装备,2013,34(10):47-48.
[24]张帧,商建国,李汉民.基于翻拍技术和条形码技术的病案数字化应用研究[J].中国数字医学,2014,9(10):101-103.
[25]刘洋,王弥,邱恺.基于病案数字化的病案复印流程再造效果评价[J].中国病案,2014,15(4):36-38.
[26]Lee DH,Hong KS,Kim NY.Effects of hospital leadership,organizational systems,and ESWOSon medical error reduction[J].Service Business,2014,10(1):1-19.
[27]范晓棠.数字化病案管理应用效果分析[J].中国病案,2017,18(6):1-3.
[28]赖丽文,王逸纯,赵淑媛.现代化信息技术在病案管理中的应用[J].中国病案,2014,15(4):34-36.
[29]樊美娜,王凯鹏,葛佳.谈病案数字化扫描服务器存储扩容[J].中国病案,2014,15(12):31-32.
[30]刘建花,栾红.病案数字化的应用效果[J].中国病案,2014,15(10):8-9.
[31]李迎新,陈能太.电子签名在医院电子病历中的实施[J].中国医学装备,2018,15(04):94-97.
[32]张明.历史纸质病案数字化工作实践探讨[J].东南国防医药,2014,16(3):327-328.