数字化智慧医疗病区质量管控研究

发布时间：2018-01-16 00:30

本文关键词：数字化智慧医疗病区质量管控研究　出处：《南方医科大学》2014年硕士论文　论文类型：学位论文

【摘要】：研究背景：住院业务是医院医疗业务的核心部分,病区住院信息系统是医院信息系统的重要组成部分之一,作为医院建设的重中之重,既是其医疗质量的综合体现,又是其诊疗技术水平的集中反映,更是衡量其整体管理水平的重要标志之一。目前,我国多数医疗机构都已开展了病区信息化建设,但整体水平仍较为落后,而基于信息化医疗的全程质量管理体系建设更是欠缺。在经济欠发达的区域,缺乏开展信息化医疗质控的硬件设施,信息化发展较快的医院已应用电子病历等系统,但对利用其进行质量控制仍缺乏研究。因此,应用信息技术促进医疗质量的持续改进成为当下迫切的需求。相比于传统的终末质量控制管理系统来说,医院信息化医疗质量控制系统更加注重对影响医疗质量因素的“防”和“治”。从两者的控制模式上看,传统的终末质量控制主要根据对出院患者病案信息的反馈来控制下一个环节的医疗质量,这种控制方式强调的是“治”,并不能起到预防作用,是一种被动管理和控制；而后者,信息化医疗质量控制则可以做到对患者病情进行实时控制,依靠现代化信息系统建立起一套完整的实时医疗质量控制模式,这套模式运行时可实现对影响医疗质量的因素(如医师误诊、用药不合理等)进行全程控制,这种控制模式强调的是“防”“治”结合,是一种主动管理。近几年,随着医院全面信息化的建设进程,我国医院病区信息化建设也初具规模。随着各种信息系统的全面应用,医院实现了住院患者整个住院期间疾病诊治和费用计算的统一管理。医院管理模式也逐步由传统管理模式向数字化管理模式转变,由经验管理、终末控制向科学管理、环节控制转变。电子病历系统、医护工作站、合理用药系统、LIS、PACS、手术麻醉、科间会诊、病历质量监控、移动医护、整体呼叫系统、科室管理等病区信息的建设为开展病区数字化质量管理与控制提供了物理基础。研究目的：借助数字化医院和医疗质量管理的相关理论,以及在对我国数字化医院智慧医疗病区建设的众多研究成果基础上,以某军队总医院数字化病区为案例,研究其医疗质量管控体系的设计构建,为数字化病区质量管控提供新的思路、方法及管理模式。研究内容：第一,数字化医院建设及医疗质量管控的现状分析。第二,病区数字化医疗质量管控需求分析。第三,设计应用数字化智慧医疗病区系统。第四,构建数字化智慧医疗病区质量管控体系。第五,对数字化智慧医疗病区及质量管控体系进行分析讨论。研究结果：一、医院病区数字化建设及医疗质量管控需求分析 1.病区数字化建设需求分析 ①病区的部分业务及管理环节缺乏相应信息系统,从而这些业务及管理工作开展只能为手工纸质模式。这就导致这些环节效率低下,容易出现差错,管理难以到位,即影响工作效率,又影响医疗及管理质量； ②部分现有信息系统功能需进一步完善,提高信息反馈的实时性。如LIS系统中,危急值管理功能需进一步完善；同样,感染监控系统能进一步增强实时环节监控功能,这样就更有利于临床及时整改。 ③部分信息系统需与电子病历进一步集成并构建临床数据中心,从而实现所有医疗数据的一元化管理和全院高度共享。 2.病区数字化医疗质量管控需求分析 ①医疗质量的全程监控体系有待进一步完善。病区的医疗质量全程监控应涵盖患者自入科至出院全程,而传统病区医疗质量监控重点关注的是针对患者的医疗行为开始后的所有医护工作； ②医疗质量实时环节监控、可追溯机制有待进一步完善。就病区医疗质量管理的全过程而言,有诸多环节仍只能以终末管理模式落实,由于缺乏实时、准确且不可抵赖的执行记录,从而使这些环节的质量管理及医疗追溯落实有一定难度； ③医疗质量管理的内容及手段有待实时完善。医疗质量监控重点关注的往往是病历质量、合理用药、感染控制等几个大的方面,而每一个大方面都牵涉到许多的指标因子及关注要点,传统粗犷的质量管理模式已很难满足日益发展的质量管理要求,而在质量管理模式精细化的过程中,又面临一个无法回避的现实---质量管理的需求永远超前于有效的质量管理手段,只有不断的拓展、完善质量管理的内容及手段才能跟上质量管理需求增长的脚步。二、数字化智慧医疗病区系统设计及应用在全面分析病区管理及医疗业务过程的基础上,从整体上把握应用需求,基于计算机和通信技术的发展,应用软件开发、数据库、物联网、信息集成等现代信息技术,设计并构建以电子病历为核心、以科室管理系统为支柱的涉及临床医疗护理、药品器材及后勤保障；绩效考核、成本核算及办公管理等多系统的数字化智慧医疗病区系统,实现医疗业务、行政事务全过程的智能化操作与自动化管理,从而建成以“病人为中心”的温馨、便捷、智能、高效的医疗服务环境。数字化智慧医疗病区系统包括临床管理和科室管理两大部分。前者以全结构化电子病历为核心,应用、集成PACS、LIS、合理用药、手术麻醉、病历质量监控、临床路径、移动医护、用血管理、出院带药、科间会诊等系统,构建“以患者为中心”的方便、舒适、安全、规范的住院诊疗服务模式,实现临床业务全面数字化；后者则包括视频监控、电子交班、药品管理、物资管理、成本管理、绩效管理、出院结算审核管理、电子政务等管理功能系统。三、数字化智慧医疗病区质量管控体系构建患者入科环节的数字化管理及质量管控。患者入科后,科室护士使用一体化医护工作站对患者信息进行入科处理,分配床位设置管床医生。然后,使用移动医护系统建立并录入患者入院评估单等记录资料。患者收床环节的数字化管理及质量管控。医生通过一体化医护工作站将患者收入床位,建立电子病历,根据患者入院诊断情况判断是否进入临床路径。医嘱开具环节的数字化管理及质量管控。对于进入临床路径管理的患者,其治疗过程按照路径设定进行,医生只需关注是否有变异即可。对于未进入临床路径管理的患者,医生在一体化医护工作站中开具医嘱,开具时合理用药系统实时判断医嘱是否有用药及配伍禁忌等。用药执行环节的数字化管理及质量管控。医院完善了药品执行环节的业务流程,引进了移动医护系统,在患者床边进行用药执行时,通过移动医护终端对患者腕带、药品条码、医护人员工号进行扫描,实现对病人身份、药品信息和执行人员的三重核对与信息记录。临床医疗护理环节的数字化管理及质量管控。医生查房时只需携带移动终端,即可在患者床边实时调取患者所有医疗资料,包括影像资料；患者体征的床边采集也由护理人员在患者床边直接录入移动医护系统,并自动同步至电子病历检验环节的数字化管理及质量管控。检验申请是在一体化医护工作站中完成,医生开具检验医嘱,护士转抄执行检验医嘱,LIS提取已执行检验医嘱自动生成申请信息,申请信息通过LIS与电子病历的系统接口自动同步至电子病历系统中。检查环节的数字化管理及质量管控。相关检查科室使用PACS提取科室发送的检查申请,安排并执行检查,执行完毕后进行检查确认,检查费用信息自动写入HIS中的患者费用信息中。手术环节的数字化管理及质量管控。为方便医生工作,已将手术麻醉系统中的手术申请模块集成进一体化医护工作站,医生在医护工作站直接开具手术申请,麻醉科使用手术麻醉系统提取手术申请,安排手术间、麻醉医生等,安排完毕后系统自动反馈医生。用血环节的数字化管理及质量管控。输血科收到申请后进行备血,备血完毕后确认,系统自动生成回馈信息提醒医生。会诊环节的数字化管理及质量管控。通过科间会诊系统与电子病历系统的集成,当受邀医生确认此信息时,即可打开此患者的电子病历,浏览该患者的所有医疗资料信息,从而可在第一时间书写会诊记录,完成会诊。病历管理环节的数字化管理及质量管控。医生书写病历时,电子病历中集成的病历质量监控系统会对病历时限、结构完整性进行实时监控、提醒,以提高病历质量,减少医疗隐患。危机值管理环节的数字化管理及质量管控。将危急值检出规程嵌入LIS、PACS等系统,当检查、检验结果出来时,系统根据判断规则自动检出危急值。感控管理环节的数字化管理及质量管控。在医院应用的新版感染控制系统对环节管理提出了明确要求,系统会结合LIS、PACS、电子病历中患者的检验检查结果、体征变化状况等每日自动分析患者管控情况并对管理人员进行提示,以利于问题的尽早发现,尽早控制。患者在科管理环节的数字化管理及质量管控。患者日常的在科管理容易成为医疗质量管理的盲区,但通过全病区覆盖的视频监控系统及医护患整体呼叫系统的应用,可在很大程度上减少由于各种意外情况引发的医疗纠纷。出院环节的数字化管理及质量管控。出院环节主要涉及患者医疗费用查询、出院带药管理、医生通知出院后至患者结算完毕离院前的医疗安全等。同时,还设置了自助评价系统,用于对住院科室及医生的医疗水平、服务质量、医德医风等进行评价。随访环节的数字化管理及质量管控。实现了医生对随访患者的自主定义筛选、对随访计划的自动生成管理、对随访任务的自动提醒、对随访资料的自动记录保存等,使得随访工作变得高效有序。研究结论：一、业务流程优化,服务理念明确住院信息系统通过计算机网络信息技术手段,改变了传统的手工操作模式,为医院提供一种全新的自动化和网络化业务操作模式。医院信息系统的应用使各个诊疗业务部门之间的业务联系通畅起来,许多原来需要人工参与的过程和环节可以削减甚至取消,使医院业务流程更加方便、高效和流畅。结合信息化的模式和信息系统的特点,对医院业务流程进行优化和重组,实现医院由传统模式管理向信息管理的跨越式发展。二、系统综合集成,信息高度共享医院数字化的核心是病人信息的共享,以数据库为中心实现病人信息的无纸化和无胶片化。数字化管理彻底改变了传统作业流程,为医务人员提供网络化工作模式提高了工作效率,方便了患者；同时,管理者可以通过网络及时获取各种医疗信息.及时做出科学决策。三、医疗行为规范,环节监控到位医院信息系统的应用,明显改变了手工操作模式下的工作随意性大、质量监督难的问题[53],为医护人员提高了规范的业务操作平台和有效的质量管理平台。①电子医疗文书取代了过去的手写医疗文书。格式规范,页面整齐,项目齐全,保留了所有修改痕迹,且可加盖电子印章保护。②规范医疗行为和过程,减少医疗中的随意性和不确定性。在医疗过程中,存在大量的操作、时限、审批、检诊、查对的监控环节,将上述规范和要求设置在信息系统中,医务人员在使用信息系统时,实时受到监控和提示,确保诊疗过程的规范和准确。③通过合理用药,药物不良反应、院内感染、危重疾病等项目的在线监控,及时提示、预警和控制诊疗过程可能出现的质量问题。④信息系统的应用大大减少了人工操作环节,同时采用数字标识和识别技术,以数据的自动识别、采集和处理替代了过去人工操作容易出错的环节。四、电子病历应用,提升智慧水平电子病历系统把原先在分散在不同信息系统的诊疗系统以病人为索引进行整合,形成病人的电子病历,为医师检索、调阅、使用、归档病人诊疗信息提供有效手段,使医师能够全面了解和掌握病人的病情,以便做出正确的诊断和处置。电子病历系统比较完整的保存了病人的诊疗数据,除了用于病人的治疗外,这些数据的积累形成了一个大型的医疗知识库,包含了病人和疾病的客观资料以及医务人员在诊治病人中的知识和智慧。通过数据分析、挖掘等工具,发现和归纳出诊疗规律,指导和辅助临床诊疗活动。电子病历还为居民健康档案提供居民在医院住院、门诊或体检期间的诊疗数据,是居民健康档案的重要组成部分。研究创新：设计了数字化智慧医疗病区平台体系架构,创新了数字化病区诊疗服务模式,应用了“以患者为中心”的安全便捷高效的诊疗流程。构建了数字化智慧医疗病区质量管控体系,显著提高了病区医疗质量和管理水平。
[Abstract]:Research background:
Inpatient service is the core part of hospital medical services, hospital ward information system is an important part of hospital information system, as a priority among priorities of the hospital construction, not only embodies the comprehensive medical quality, and reflects its diagnosis and treatment level of technology, it is one of the important symbol of the overall management level. At present, the majority of medical institutions in our country have been carried out in informatization construction, but the overall level is still relatively backward, and based on the construction of the whole quality management system of medical information is lacking. In the underdeveloped areas, the lack of information of medical quality control facilities, the rapid development of hospital informatization has been applied to electronic medical records system but, to control the quality of the lack of study. Therefore, the application of information technology to promote the continuous improvement of medical quality has become the urgent demand.
Compared to the traditional terminal quality control management system, medical quality control in hospital information system pays more attention to the factors that affect the quality of medical "defense" and "governance". From the control models of the two end point of view, the traditional quality control is mainly based on the feedback information of the medical records of patients discharged to control the next link the quality of medical care, emphasizing the control mode is the "rule", and can play a preventive role, is a kind of passive management and control; the latter, the information of medical quality control can do the real-time control of the patient's condition, relying on modern information system to establish a complete set of real-time control of medical quality, the mode of operation can be realized when the influence factors on the quality of medical care (such as medical misdiagnosis, medication unreasonable etc.) for the whole control, the control mode that is "prevention" "treatment" is a combination of. Active management.
In recent years, with the comprehensive hospital information construction process of our country hospital ward informatization construction has begun to take shape. With the comprehensive application of various information systems, to achieve unified management of the entire hospital hospitalization expenses and hospitalization. During the calculation of disease hospital management pattern is also changing to the digital management mode from the traditional management mode gradually, by experience terminal control to management, scientific management, link control. Medical workstation electronic medical record system, reasonable use system, LIS, PACS, surgery, Department consultation, quality monitoring, mobile medical records, the overall call system, construction department management unit information provides a physical basis for carrying out quality management and Digital Ward control.
The purpose of the study is:
With the theory of digital hospital and medical quality management, and based on the construction of digital hospital medical ward wisdom in China a large number of research results, in a military general hospital digital ward as a case, the construction design of the medical quality control system, to provide new ideas for the digital in quality control and management methods. Model.
Research content:
First, the present situation analysis of the construction of digital hospital and the management and control of medical quality.
Second, the demand analysis of digital medical quality control and control in the ward area.
Third, the digital intelligent medical ward system is designed and applied.
Fourth, the construction of digital intelligent medical ward quality control system.
Fifth, the digital intelligent medical ward and the quality control and control system are analyzed and discussed.
The results of the study:
First, the demand analysis of hospital ward digital construction and medical quality control and control
Analysis on the demand of digital construction in 1. ward area
Part of the business and management aspects of the lack of ward information system, thus the operation and management of the work carried out only for manual paper mode. This leads to the inefficient, prone to error, management is difficult to place, which affect the efficiency and effect of medical and management quality;
Part of the existing information system functions need further improvement to improve the real-time performance of information feedback. For example, the critical value management function of LIS system needs further improvement. Similarly, infection monitoring system can further enhance the monitoring function of real-time links, which is more conducive to clinical timely modification.
Part of the information system needs further integration with electronic medical records and construction of clinical data center, so as to achieve unified management of all medical data and highly shared hospital wide.
Demand analysis of digital medical quality control and control in 2. ward area
(1) the whole process monitoring system of medical quality needs further improvement. The whole quality control of ward's medical quality should cover the whole process of patient's self admission to hospital discharge, while the traditional ward quality monitoring focuses on all medical care work aiming at patients' medical behavior.
The medical quality real-time link monitoring, traceability mechanism needs to be further improved. The whole process of quality management of medical wards, there are many aspects still only in the terminal management mode to implement, because of the lack of real-time, accurate and non repudiation of the implementation record, so that the quality management and the implementation of these medical links back there is a certain degree of difficulty;
The content and means of the medical quality management needs to be improved. The real-time monitor of medical quality is often the focus of attention of the quality of medical records, the rational use of drugs, many aspects of infection control, and every aspect involves many factors and key points of the index, the traditional rough quality management mode has been difficult to meet the requirements of quality management the growing, and in the process of fine quality management mode, is facing an unavoidable reality --- quality management needs always ahead of effective quality management methods, only continue to expand, to improve the content and means of quality management quality management needs to keep up with growth pace.
Two, the design and application of the digital intelligent medical ward system
Based on comprehensive analysis of ward management and medical business process, grasp the application requirements on the whole, the development of computer and communication technology based on the development of application software, databases, networking, information integration of modern information technology, design and construction of electronic medical records as the core, the department management system relates to clinical medical and nursing support the drug, equipment and logistics; performance assessment, cost accounting and office management system of digital intelligent medical ward system, realize the intelligent operation of medical services, the whole process of administrative affairs and automation management, in order to build "taking patients as the center" warm, intelligent, convenient and efficient medical service environment.
Digital medical wisdom ward clinical management and department management system includes two parts. In the first full structured electronic medical records as the core, application, integration of PACS, LIS, rational use of drugs, anesthesia, monitoring the quality of medical records, clinical pathway, mobile medical, blood management, discharge medication, interdisciplinary consultation system, to construct the patients as the center of "convenient, comfortable, safe, standardized inpatient service mode, clinical comprehensive business digital; the latter includes video surveillance, electronic shift, drug management, material management, cost management, performance management, settlement audit management hospital, e-government management system.
Three, construction of quality control and control system in digital intelligent medical ward
Digital management and quality control of patients into the branch links. Patients after into the hospital, nurses use integrative medical treatment on patients of workstation into the information distribution, bed set up tube bed doctor. Then, the use of mobile medical system and input patients admission assessment single recorded data.
The digital management and quality control of the patients' bed collection link. The doctors set up the electronic medical record through the integrated medical workstation, and judged whether to enter the clinical pathway according to the patient's admission diagnosis.
Digital management and quality control advising links. To enter the clinical pathway management of patients, the treatment process is carried out according to the path set, the doctor only needs to pay attention to whether there is variation can not enter. For clinical pathway management of patients, doctors in the integrative medical workstation orders, issued when the real-time judgment whether medication orders rational medication system and incompatibility.
Digital management and quality control aspects of the implementation of the hospital medication. Improve the pharmaceutical aspects of the implementation of the business process, the introduction of mobile medical system, drug enforcement at the patient's bedside, the mobile medical drugs on patients with terminal wristband, barcode, work staff scan, to achieve the patient identity, three check and record information of drugs information and executive staff.
Digital management and quality control of medical nursing links. The doctor rounds only need to carry a mobile terminal, can be in all medical data of the patients bedside real-time transfer of patients, including video data acquisition; bedside signs also patients by nursing personnel at the patient's bedside direct entry of mobile medical system, and automatic synchronization to electronic medical records
Digital management and quality control inspection. The test application is completed in the integrated medical workstation, the doctor issued the test orders, nurses made perform inspection orders, LIS extraction has been performed the test orders automatically generated application information, application information system through the interface of LIS and electronic medical records automatically synchronized to the electronic medical record system.
The digital management and quality control of the inspection link. The relevant inspection departments use PACS to extract the inspection applications sent by the Department, arrange and execute the inspection, check and confirm after the completion of the inspection, and check the cost information to automatically write to the patient's expense information in HIS.
Digital management and quality control. For the convenience of operation doctor work, has been in operation anesthesia application module integrated into the integrated health care in medical workstation, doctor workstation directly issue surgery for anesthesia using anesthesia system extraction surgery apply, arrange surgery, anesthesia doctor, the doctor arranged after the automatic feedback system.
Blood link digital management and quality control and control. Blood transfusion department received the application for blood preparation, after the blood preparation was confirmed, the system automatically generated feedback information to remind the doctor.
Digital management and quality management consultation links. Through the integration of interdisciplinary consultation system and electronic medical record system, when the doctor was invited to confirm this information, you can open the electronic medical records of the patients, the patients of all medical data browsing information, which can complete the consultation in the first time writing consultation records.
The digital management and quality control of medical records management. When doctors write medical records, the integrated medical record quality monitoring system in electronic medical records will monitor the time limit and structural integrity of medical records in real time, and remind them to improve the quality of medical records and reduce medical risks.
The digital management and quality control of the crisis value management link. The system of critical value detection is embedded in LIS, PACS and other systems. When the inspection result comes out, the system automatically detectable the critical value according to the rule of judgement.
Digital management and quality control management of infection control. The control system puts forward specific requirements of management in the new hospital infection application, the system will be combined with LIS, PACS, the inspection results of patients in the electronic medical record, signs of change in daily automatic control and analysis with tips on management, discover as soon as possible, as soon as possible in order to control the problem.
Digital management in science management and quality control of patients. Patients in daily department management to become blind medical quality management, but the application of video monitoring system through the full coverage of the whole patient and medical ward call system, can reduce medical disputes caused by the unexpected situation to a great extent.
Digital management and quality control. The main part of hospital discharge process involving medical expenses with query, discharge medication management, doctors informed patients after discharge from hospital to settlement before medical security. At the same time, also set up a self evaluation system for quality of hospital, and the doctor's medical service level, evaluation of medical ethics Yifeng.
The digital management and quality control of the follow-up link realized the doctors' independent definition and screening of follow-up patients.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R197.32

【参考文献】