某三级医院临床信息系统建设及应用研究

  本文关键词：某三级医院临床信息系统建设及应用研究，由笔耕文化传播整理发布。

        研究背景医院信息化建设在保障与支持医疗体制改革顺利进行和保证医院可持续发展等方面的作用日益显著,从卫生部颁布的《三级综合医院评审标准实施细则》可以看出,信息化所占比重最大。在其设置的378项评审内容与监测指标中,与信息化直接相关或间接相关的条款最多,内容覆盖门诊就医、住院诊疗、安全管控、院务保障及信息公开等各个层次,触及业务流程、医疗质量、工作效率、服务监督、综合管控等各个环节。信息化已与医院全面建设与发展息息相关,并为医院等级评审及医院决策提供有力的支撑。医院等级评审对三级医院临床信息系统提出了明确要求,即应建立电子病历系统和至少12种临床路径,因此开展医院临床信息系统建设研究具有重要的现实意义。研究目的本文通过医院临床信息系统建设方法及应用研究,以探讨提高医疗质量与效率的方式方法,着力探讨信息化实现医疗业务流程的优化与创新的途径和手段,探索依托信息化加强临床诊疗风险的监测与控制的模式和机制,针对临沂市人民医院的信息系统起步较晚、信息系统的建设已经跟不上医院的发展的具体情况,利用三级医院评审的时机,医院启动了新一轮信息系统建设,研究如何围绕临床应用为核心,推进医院临床信息系统的中长期建设。研究方法文献调研通过查阅与医院临床信息系统建设方法研究有关的文献、资料及书籍,了解到国内外医院临床信息系统发展进程及研究现状,根据以前研究基础设计了临床路径应用调研基准,从而为本文的调查研究提供一定的参考依据。定性访谈法我们对科室临床医生进行了深度访谈,内容包括目前临床信息系统建设和应用状况以及应用取得的效果,在实地调查以及课题开展中,注重咨询医院一线工作人员和相关领域专家教授的意见和建议,使研究更加科学。主要结果信息化与医院全面建设与发展息息相关,并为各项评审及医院决策提供有力的支撑。因此医院要转变观念,从根本上改变为应付评审工作而做信息化的想法,应该按标准建设医院信息化,应按标准管理医院信息化,减少随意性和盲目性,首先应明确临床信息系统建设的范围和内容。临床信息系统的建设是一个复杂的过程,不是对各子系统进行简单的累加过程,首先要对已有的信息系统进行分析,理清各个系统之间的关系；其次分析已有的面向临床的信息子系统,明确这些子系统在临床应用方面的缺陷；最后构建符合医院长期持续发展的信息系统基础架构。通过调查分析的结果,我们可以得出医院临床信息系统的建设路径,进而明确各个子系统需要改造的工作量。临床信息系统建设的路径应首先以CPOE为核心推动医疗流程的建设,其次利用CPOE驱动电子病历文书系统,最后在CPOE和电子病历文书的基础上创建临床路径系统,从而实现临床数据仓库(CDR),最终为医院信息平台的建设奠定基础。结论与建议本文对临床信息系统子系统的设计和建设方法进行论述,并给出了当前形势下适合医院发展的临床信息系统的建设范围和方法。推进临床信息系统建设是医院信息化的长期目标,应充分认识到在医院现有信息系统现状,应在现有信息系统的基础上有序可控发展。在临床信息系统的建设过程中必须兼顾短期目标和中长期目标,不能偏重于短期目标而忽视了医院信息化发展的中长期规划,造成信息系统推倒重来；也不能偏重于中长期规划而忽视三级医院评审的短期紧急目标,造成三级医院评审遇到巨大风险,通过合理的软件技术,既能满足三级医院等级评审工作要求,又能兼顾医院信息系统的中长期发展规划。临床信息系统的建设需要临床各业务科室的配合才可以成功,这与普通的信息系统的建设具有明显的区别,由于临床信息系统涉及的科室和人员广泛,其项目管理变得异常复杂和艰难。因此,信息部门应该对临床信息系统的推广有足够的思想准备。借助于三级评审,临沂市人民医院启动了临床信息系统的建设,这个项目对于信息部门还是临床业务部门都是一个考验。经过充分的沟通,临床信息系统的建设方案已经明确,计划经过2年的项目建设和推广,借助于本课题的研究,以下方面在实施过程依然需要不断改进和细化·临床信息系统所依托的基础设施的建设,重点是基于集成平台的分层设计,需要在下一步的建设中进一步完善。·闭环CPOE所包含的移动医护功能还需要进一步研究；·临床路径的知识库建设尚需要与标准进行对接；·CDR建设的内容还需要明确。由于临床信息系统的建设是一个长期的过程,从部分已经上线的系统来看,已经取得了短期的效益,改变了临床科室对于信息系统的看法,使得医院管理层和临床科室已经具备了信息系统改进管理方法和手段。

    BackgroundThe role of hospital information construction is becoming increasingly significant in guaranteeing and supporting smooth reform of the health care system as well as sustainable development of hospitals. From the implementation regulations of accreditation standards for tertiary general hospitals issued by the Ministry of Health, we can see that informatization takes the biggest proportion. In the378items of evaluation content and monitoring indexes, information technology is directly relevant or indirectly related to the most articles, with the content covering various levels such as outpatient service, inpatient diagnosis and treatment, security control, hospital affair supporting system and information disclosure, touching different links of business process, medical quality, work efficiency, service supervision and comprehensive control, etc. Information has become closely related to overall hospital construction and development, providing powerful support for hospital accreditation and decision-making. Hospital accreditation puts forward clear requirements for the clinical information system of tertiary hospitals, namely, the establishment of an electronic medical record system and at least12kinds of clinical pathways. Therefore, it is of important practical significance to carry out research on hospital clinical information construction.ObjectivesBy the hospital clinical information system construction methods and applied research to improve health care quality and efficiency, efforts to explore the ways and means of hospital information to achieve medical business process optimization and innovation, discover models and mechanisms to enhance the risk of clinical diagnosis and treatment monitoring timing control.For the late start of Linyi People’s Hospital information systems, construction of hospital information have been behind the development of the hospital, By the time of three hospital accreditation, the hospital launched a new round of information systems building, focus on the clinical application as the core, to promote the long-term building of the hospital clinical information system.MethodsLiterature researchAccess to literature, information and books related to the hospital clinical information system construction, to understand the process of development and research status of hospital clinical information system at home and abroad, based on previous research-based design research basis of clinical path, to provide a reference basis to this article research. Qualitative interviewWe organized a depth interviews with clinicians, collected the data of application and effect of clinical information system construction. In the ground surveys, as well as topics, pay attention to collect the comments and suggestions from hospital front-line staff and experts and professors in related fields, to make research more scientific.Main ResultsThe construction of hospital information is closely related to the development of hospital building, and provide strong support for the assessment and hospital decision-making. Hospitals should alter the past idea cope with the assessment, and the hospital information should be according to the standard construction of hospitals, to reduce the randomness and blindness, we must first clear the scope and content of the construction of hospital clinical information.Construction of clinical information systems is a complex process, not a simple accumulation process for each subsystem, we must first analyze the existing information system to sort out the relationship between the various systems; Second, analysis the existing clinical-oriented information subsystem, to clear these subsystems defects in clinical applications; finally, build long-term sustainable development in line with the hospital information system infrastructure. By the results of the survey, we can draw the path of the construction of the hospital clinical information systems, and then clear the need to transform the workload of each subsystem.The path of the clinical information system should first put CPOE as a core to promote the construction of the medical process, followed by the use of CPOE-driven electronic medical records clerical system, created clinical pathway system based on CPOE and electronic medical records instruments, to achieve the clinical data repository (CDR). Eventually,lay the foundation for the construction of hospital information platform.The clinical application systems include the followings:POEMedical Records SecretariesClinical PathwayClinical Data Repository (CDR)Conclusions and suggestionsThis article discusses the design and construction of the subsystem of clinical information systems, and given the scope and methods of the construction of the current situation of clinical information systems for hospital development.To promote the construction of clinical information systems is a long-term goal of the hospital, the status of existing hospital information system should been fully recognized and orderly controlled and developed. The short-term goals and long-term goals must be taken into account in the construction process of the clinical information system, we should neither emphasis on short-term goals while ignoring the long-term planning; nor emphasis on long-term planning and neglect short-term emergency assessment targets of the tertiary hospitals, resulting in three hospital accreditation face enormous risks. By reasonable software technology, both to meet the tertiary hospital grade assessment work requirements, while maintaining the long-term development plan of the hospital information system.The construction of clinical information system needs the co-ordination of the business sections of the clinical, which has obvious difference with the common construction of information systems. Due to the wide range of departments and personnel, project management becomes extremely complex and difficult. Therefore, the information sector should has mental preparation for the promotion of the clinical information system.Now, Linyi People’s Hospital starts the construction of clinical information system by means of the tertiary hospital accreditation, the project is a test for both the information sector and clinical operations department. The plan of construction program of clinical information system has clear after two years’project construction and promotion, by means of the research projects, the following aspects in the implementation process still need to be improve and refine.O Clinical information system emphasized on hierarchical design,which based on integration platform, needs to further improved in the next stage of construction. Oclosed-loop CPOE contained mobile health care function needs further research; O Knowledge of the clinical pathway construction needs to docking with the standard;OCDR building needs to be clear.As the construction of clinical information system is a long-term process, from the part of the on-line system view, it has been made short-term benefits to change the opinion of clinical departments for information systems, hospital management and clinical departments have already had the methods and means of improving management.

某三级医院临床信息系统建设及应用研究

中文摘要6-9ABSTRACT9-12符号说明13-14一、前言14-18二、医院临床信息系统建设18-29    2.1 医院信息化现状分析18-22    2.2 医院临床信息系统建设路径分析22-29三、电子病历系统29-32    3.1 电子病历简述29-30    3.2 电子病历发展30-31    3.3 电子病历相关规范31-32    3.4 电子病历发展趋势32四、CPOE和临床路径32-38    4.1 CPOE和临床路径的现状分析33    4.2 实施方法33-35    4.3 应用效果35-36    4.4 知识库建立36-37    4.5 结论37-38五、电子病历文书38-44    5.1 现状38-39    5.2 结构化数据存储39-41    5.3 电子病历文书的集成41-42    5.4 动态模板42-43    5.5 病历质控管理43-44    5.6 结论44六、医院感染管理44-49    6.1 概述44-45    6.2 相关研究45    6.3 实现方法45-48    6.4 应用效果48    6.5 结论48-49七、小结和展望49-51    7.1 临床信息子系统的建设路径49    7.2 临床信息系统建设的范围和内容49-51参考文献51-55致谢55-56攻读硕士学位期间发表论文情况56-57附件57

  本文关键词：某三级医院临床信息系统建设及应用研究，由笔耕文化传播整理发布。