本文關(guān)鍵詞：數(shù)字化智慧醫(yī)療病區(qū)質(zhì)量管控研究　出處：《南方醫(yī)科大學(xué)》2014年碩士論文　論文類(lèi)型：學(xué)位論文

  更多相關(guān)文章： 數(shù)字化 智慧醫(yī)療 醫(yī)院 病區(qū) 質(zhì)量管控

【摘要】：研究背景： 住院業(yè)務(wù)是醫(yī)院醫(yī)療業(yè)務(wù)的核心部分,病區(qū)住院信息系統(tǒng)是醫(yī)院信息系統(tǒng)的重要組成部分之一,作為醫(yī)院建設(shè)的重中之重,既是其醫(yī)療質(zhì)量的綜合體現(xiàn),又是其診療技術(shù)水平的集中反映,更是衡量其整體管理水平的重要標(biāo)志之一。目前,我國(guó)多數(shù)醫(yī)療機(jī)構(gòu)都已開(kāi)展了病區(qū)信息化建設(shè),但整體水平仍較為落后,而基于信息化醫(yī)療的全程質(zhì)量管理體系建設(shè)更是欠缺。在經(jīng)濟(jì)欠發(fā)達(dá)的區(qū)域,缺乏開(kāi)展信息化醫(yī)療質(zhì)控的硬件設(shè)施,信息化發(fā)展較快的醫(yī)院已應(yīng)用電子病歷等系統(tǒng),但對(duì)利用其進(jìn)行質(zhì)量控制仍缺乏研究。因此,應(yīng)用信息技術(shù)促進(jìn)醫(yī)療質(zhì)量的持續(xù)改進(jìn)成為當(dāng)下迫切的需求。 相比于傳統(tǒng)的終末質(zhì)量控制管理系統(tǒng)來(lái)說(shuō),醫(yī)院信息化醫(yī)療質(zhì)量控制系統(tǒng)更加注重對(duì)影響醫(yī)療質(zhì)量因素的“防”和“治”。從兩者的控制模式上看,傳統(tǒng)的終末質(zhì)量控制主要根據(jù)對(duì)出院患者病案信息的反饋來(lái)控制下一個(gè)環(huán)節(jié)的醫(yī)療質(zhì)量,這種控制方式強(qiáng)調(diào)的是“治”,并不能起到預(yù)防作用,是一種被動(dòng)管理和控制；而后者,信息化醫(yī)療質(zhì)量控制則可以做到對(duì)患者病情進(jìn)行實(shí)時(shí)控制,依靠現(xiàn)代化信息系統(tǒng)建立起一套完整的實(shí)時(shí)醫(yī)療質(zhì)量控制模式,這套模式運(yùn)行時(shí)可實(shí)現(xiàn)對(duì)影響醫(yī)療質(zhì)量的因素(如醫(yī)師誤診、用藥不合理等)進(jìn)行全程控制,這種控制模式強(qiáng)調(diào)的是“防”“治”結(jié)合,是一種主動(dòng)管理。 近幾年,隨著醫(yī)院全面信息化的建設(shè)進(jìn)程,我國(guó)醫(yī)院病區(qū)信息化建設(shè)也初具規(guī)模。隨著各種信息系統(tǒng)的全面應(yīng)用,醫(yī)院實(shí)現(xiàn)了住院患者整個(gè)住院期間疾病診治和費(fèi)用計(jì)算的統(tǒng)一管理。醫(yī)院管理模式也逐步由傳統(tǒng)管理模式向數(shù)字化管理模式轉(zhuǎn)變,由經(jīng)驗(yàn)管理、終末控制向科學(xué)管理、環(huán)節(jié)控制轉(zhuǎn)變。電子病歷系統(tǒng)、醫(yī)護(hù)工作站、合理用藥系統(tǒng)、LIS、PACS、手術(shù)麻醉、科間會(huì)診、病歷質(zhì)量監(jiān)控、移動(dòng)醫(yī)護(hù)、整體呼叫系統(tǒng)、科室管理等病區(qū)信息的建設(shè)為開(kāi)展病區(qū)數(shù)字化質(zhì)量管理與控制提供了物理基礎(chǔ)。 研究目的： 借助數(shù)字化醫(yī)院和醫(yī)療質(zhì)量管理的相關(guān)理論,以及在對(duì)我國(guó)數(shù)字化醫(yī)院智慧醫(yī)療病區(qū)建設(shè)的眾多研究成果基礎(chǔ)上,以某軍隊(duì)總醫(yī)院數(shù)字化病區(qū)為案例,研究其醫(yī)療質(zhì)量管控體系的設(shè)計(jì)構(gòu)建,為數(shù)字化病區(qū)質(zhì)量管控提供新的思路、方法及管理模式。 研究?jī)?nèi)容： 第一,數(shù)字化醫(yī)院建設(shè)及醫(yī)療質(zhì)量管控的現(xiàn)狀分析。 第二,病區(qū)數(shù)字化醫(yī)療質(zhì)量管控需求分析。 第三,設(shè)計(jì)應(yīng)用數(shù)字化智慧醫(yī)療病區(qū)系統(tǒng)。 第四,構(gòu)建數(shù)字化智慧醫(yī)療病區(qū)質(zhì)量管控體系。 第五,對(duì)數(shù)字化智慧醫(yī)療病區(qū)及質(zhì)量管控體系進(jìn)行分析討論。 研究結(jié)果： 一、醫(yī)院病區(qū)數(shù)字化建設(shè)及醫(yī)療質(zhì)量管控需求分析 1.病區(qū)數(shù)字化建設(shè)需求分析 ①病區(qū)的部分業(yè)務(wù)及管理環(huán)節(jié)缺乏相應(yīng)信息系統(tǒng),從而這些業(yè)務(wù)及管理工作開(kāi)展只能為手工紙質(zhì)模式。這就導(dǎo)致這些環(huán)節(jié)效率低下,容易出現(xiàn)差錯(cuò),管理難以到位,即影響工作效率,又影響醫(yī)療及管理質(zhì)量； ②部分現(xiàn)有信息系統(tǒng)功能需進(jìn)一步完善,提高信息反饋的實(shí)時(shí)性。如LIS系統(tǒng)中,危急值管理功能需進(jìn)一步完善；同樣,感染監(jiān)控系統(tǒng)能進(jìn)一步增強(qiáng)實(shí)時(shí)環(huán)節(jié)監(jiān)控功能,這樣就更有利于臨床及時(shí)整改。 ③部分信息系統(tǒng)需與電子病歷進(jìn)一步集成并構(gòu)建臨床數(shù)據(jù)中心,從而實(shí)現(xiàn)所有醫(yī)療數(shù)據(jù)的一元化管理和全院高度共享。 2.病區(qū)數(shù)字化醫(yī)療質(zhì)量管控需求分析 ①醫(yī)療質(zhì)量的全程監(jiān)控體系有待進(jìn)一步完善。病區(qū)的醫(yī)療質(zhì)量全程監(jiān)控應(yīng)涵蓋患者自入科至出院全程,而傳統(tǒng)病區(qū)醫(yī)療質(zhì)量監(jiān)控重點(diǎn)關(guān)注的是針對(duì)患者的醫(yī)療行為開(kāi)始后的所有醫(yī)護(hù)工作； ②醫(yī)療質(zhì)量實(shí)時(shí)環(huán)節(jié)監(jiān)控、可追溯機(jī)制有待進(jìn)一步完善。就病區(qū)醫(yī)療質(zhì)量管理的全過(guò)程而言,有諸多環(huán)節(jié)仍只能以終末管理模式落實(shí),由于缺乏實(shí)時(shí)、準(zhǔn)確且不可抵賴(lài)的執(zhí)行記錄,從而使這些環(huán)節(jié)的質(zhì)量管理及醫(yī)療追溯落實(shí)有一定難度； ③醫(yī)療質(zhì)量管理的內(nèi)容及手段有待實(shí)時(shí)完善。醫(yī)療質(zhì)量監(jiān)控重點(diǎn)關(guān)注的往往是病歷質(zhì)量、合理用藥、感染控制等幾個(gè)大的方面,而每一個(gè)大方面都牽涉到許多的指標(biāo)因子及關(guān)注要點(diǎn),傳統(tǒng)粗獷的質(zhì)量管理模式已很難滿(mǎn)足日益發(fā)展的質(zhì)量管理要求,而在質(zhì)量管理模式精細(xì)化的過(guò)程中,又面臨一個(gè)無(wú)法回避的現(xiàn)實(shí)---質(zhì)量管理的需求永遠(yuǎn)超前于有效的質(zhì)量管理手段,只有不斷的拓展、完善質(zhì)量管理的內(nèi)容及手段才能跟上質(zhì)量管理需求增長(zhǎng)的腳步。 二、數(shù)字化智慧醫(yī)療病區(qū)系統(tǒng)設(shè)計(jì)及應(yīng)用 在全面分析病區(qū)管理及醫(yī)療業(yè)務(wù)過(guò)程的基礎(chǔ)上,從整體上把握應(yīng)用需求,基于計(jì)算機(jī)和通信技術(shù)的發(fā)展,應(yīng)用軟件開(kāi)發(fā)、數(shù)據(jù)庫(kù)、物聯(lián)網(wǎng)、信息集成等現(xiàn)代信息技術(shù),設(shè)計(jì)并構(gòu)建以電子病歷為核心、以科室管理系統(tǒng)為支柱的涉及臨床醫(yī)療護(hù)理、藥品器材及后勤保障；績(jī)效考核、成本核算及辦公管理等多系統(tǒng)的數(shù)字化智慧醫(yī)療病區(qū)系統(tǒng),實(shí)現(xiàn)醫(yī)療業(yè)務(wù)、行政事務(wù)全過(guò)程的智能化操作與自動(dòng)化管理,從而建成以“病人為中心”的溫馨、便捷、智能、高效的醫(yī)療服務(wù)環(huán)境。 數(shù)字化智慧醫(yī)療病區(qū)系統(tǒng)包括臨床管理和科室管理兩大部分。前者以全結(jié)構(gòu)化電子病歷為核心,應(yīng)用、集成PACS、LIS、合理用藥、手術(shù)麻醉、病歷質(zhì)量監(jiān)控、臨床路徑、移動(dòng)醫(yī)護(hù)、用血管理、出院帶藥、科間會(huì)診等系統(tǒng),構(gòu)建“以患者為中心”的方便、舒適、安全、規(guī)范的住院診療服務(wù)模式,實(shí)現(xiàn)臨床業(yè)務(wù)全面數(shù)字化；后者則包括視頻監(jiān)控、電子交班、藥品管理、物資管理、成本管理、績(jī)效管理、出院結(jié)算審核管理、電子政務(wù)等管理功能系統(tǒng)。 三、數(shù)字化智慧醫(yī)療病區(qū)質(zhì)量管控體系構(gòu)建 患者入科環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控�；颊呷肟坪�,科室護(hù)士使用一體化醫(yī)護(hù)工作站對(duì)患者信息進(jìn)行入科處理,分配床位設(shè)置管床醫(yī)生。然后,使用移動(dòng)醫(yī)護(hù)系統(tǒng)建立并錄入患者入院評(píng)估單等記錄資料。 患者收床環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。醫(yī)生通過(guò)一體化醫(yī)護(hù)工作站將患者收入床位,建立電子病歷,根據(jù)患者入院診斷情況判斷是否進(jìn)入臨床路徑。 醫(yī)囑開(kāi)具環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。對(duì)于進(jìn)入臨床路徑管理的患者,其治療過(guò)程按照路徑設(shè)定進(jìn)行,醫(yī)生只需關(guān)注是否有變異即可。對(duì)于未進(jìn)入臨床路徑管理的患者,醫(yī)生在一體化醫(yī)護(hù)工作站中開(kāi)具醫(yī)囑,開(kāi)具時(shí)合理用藥系統(tǒng)實(shí)時(shí)判斷醫(yī)囑是否有用藥及配伍禁忌等。 用藥執(zhí)行環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。醫(yī)院完善了藥品執(zhí)行環(huán)節(jié)的業(yè)務(wù)流程,引進(jìn)了移動(dòng)醫(yī)護(hù)系統(tǒng),在患者床邊進(jìn)行用藥執(zhí)行時(shí),通過(guò)移動(dòng)醫(yī)護(hù)終端對(duì)患者腕帶、藥品條碼、醫(yī)護(hù)人員工號(hào)進(jìn)行掃描,實(shí)現(xiàn)對(duì)病人身份、藥品信息和執(zhí)行人員的三重核對(duì)與信息記錄。 臨床醫(yī)療護(hù)理環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。醫(yī)生查房時(shí)只需攜帶移動(dòng)終端,即可在患者床邊實(shí)時(shí)調(diào)取患者所有醫(yī)療資料,包括影像資料；患者體征的床邊采集也由護(hù)理人員在患者床邊直接錄入移動(dòng)醫(yī)護(hù)系統(tǒng),并自動(dòng)同步至電子病歷 檢驗(yàn)環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。檢驗(yàn)申請(qǐng)是在一體化醫(yī)護(hù)工作站中完成,醫(yī)生開(kāi)具檢驗(yàn)醫(yī)囑,護(hù)士轉(zhuǎn)抄執(zhí)行檢驗(yàn)醫(yī)囑,LIS提取已執(zhí)行檢驗(yàn)醫(yī)囑自動(dòng)生成申請(qǐng)信息,申請(qǐng)信息通過(guò)LIS與電子病歷的系統(tǒng)接口自動(dòng)同步至電子病歷系統(tǒng)中。 檢查環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。相關(guān)檢查科室使用PACS提取科室發(fā)送的檢查申請(qǐng),安排并執(zhí)行檢查,執(zhí)行完畢后進(jìn)行檢查確認(rèn),檢查費(fèi)用信息自動(dòng)寫(xiě)入HIS中的患者費(fèi)用信息中。 手術(shù)環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。為方便醫(yī)生工作,已將手術(shù)麻醉系統(tǒng)中的手術(shù)申請(qǐng)模塊集成進(jìn)一體化醫(yī)護(hù)工作站,醫(yī)生在醫(yī)護(hù)工作站直接開(kāi)具手術(shù)申請(qǐng),麻醉科使用手術(shù)麻醉系統(tǒng)提取手術(shù)申請(qǐng),安排手術(shù)間、麻醉醫(yī)生等,安排完畢后系統(tǒng)自動(dòng)反饋醫(yī)生。 用血環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。輸血科收到申請(qǐng)后進(jìn)行備血,備血完畢后確認(rèn),系統(tǒng)自動(dòng)生成回饋信息提醒醫(yī)生。 會(huì)診環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。通過(guò)科間會(huì)診系統(tǒng)與電子病歷系統(tǒng)的集成,當(dāng)受邀醫(yī)生確認(rèn)此信息時(shí),即可打開(kāi)此患者的電子病歷,瀏覽該患者的所有醫(yī)療資料信息,從而可在第一時(shí)間書(shū)寫(xiě)會(huì)診記錄,完成會(huì)診。 病歷管理環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。醫(yī)生書(shū)寫(xiě)病歷時(shí),電子病歷中集成的病歷質(zhì)量監(jiān)控系統(tǒng)會(huì)對(duì)病歷時(shí)限、結(jié)構(gòu)完整性進(jìn)行實(shí)時(shí)監(jiān)控、提醒,以提高病歷質(zhì)量,減少醫(yī)療隱患。 危機(jī)值管理環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。將危急值檢出規(guī)程嵌入LIS、PACS等系統(tǒng),當(dāng)檢查、檢驗(yàn)結(jié)果出來(lái)時(shí),系統(tǒng)根據(jù)判斷規(guī)則自動(dòng)檢出危急值。 感控管理環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。在醫(yī)院應(yīng)用的新版感染控制系統(tǒng)對(duì)環(huán)節(jié)管理提出了明確要求,系統(tǒng)會(huì)結(jié)合LIS、PACS、電子病歷中患者的檢驗(yàn)檢查結(jié)果、體征變化狀況等每日自動(dòng)分析患者管控情況并對(duì)管理人員進(jìn)行提示,以利于問(wèn)題的盡早發(fā)現(xiàn),盡早控制。 患者在科管理環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控�；颊呷粘５脑诳乒芾砣菀壮蔀獒t(yī)療質(zhì)量管理的盲區(qū),但通過(guò)全病區(qū)覆蓋的視頻監(jiān)控系統(tǒng)及醫(yī)護(hù)患整體呼叫系統(tǒng)的應(yīng)用,可在很大程度上減少由于各種意外情況引發(fā)的醫(yī)療糾紛。 出院環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。出院環(huán)節(jié)主要涉及患者醫(yī)療費(fèi)用查詢(xún)、出院帶藥管理、醫(yī)生通知出院后至患者結(jié)算完畢離院前的醫(yī)療安全等。同時(shí),還設(shè)置了自助評(píng)價(jià)系統(tǒng),用于對(duì)住院科室及醫(yī)生的醫(yī)療水平、服務(wù)質(zhì)量、醫(yī)德醫(yī)風(fēng)等進(jìn)行評(píng)價(jià)。 隨訪(fǎng)環(huán)節(jié)的數(shù)字化管理及質(zhì)量管控。實(shí)現(xiàn)了醫(yī)生對(duì)隨訪(fǎng)患者的自主定義篩選、對(duì)隨訪(fǎng)計(jì)劃的自動(dòng)生成管理、對(duì)隨訪(fǎng)任務(wù)的自動(dòng)提醒、對(duì)隨訪(fǎng)資料的自動(dòng)記錄保存等,使得隨訪(fǎng)工作變得高效有序。 研究結(jié)論： 一、業(yè)務(wù)流程優(yōu)化,服務(wù)理念明確 住院信息系統(tǒng)通過(guò)計(jì)算機(jī)網(wǎng)絡(luò)信息技術(shù)手段,改變了傳統(tǒng)的手工操作模式,為醫(yī)院提供一種全新的自動(dòng)化和網(wǎng)絡(luò)化業(yè)務(wù)操作模式。醫(yī)院信息系統(tǒng)的應(yīng)用使各個(gè)診療業(yè)務(wù)部門(mén)之間的業(yè)務(wù)聯(lián)系通暢起來(lái),許多原來(lái)需要人工參與的過(guò)程和環(huán)節(jié)可以削減甚至取消,使醫(yī)院業(yè)務(wù)流程更加方便、高效和流暢。結(jié)合信息化的模式和信息系統(tǒng)的特點(diǎn),對(duì)醫(yī)院業(yè)務(wù)流程進(jìn)行優(yōu)化和重組,實(shí)現(xiàn)醫(yī)院由傳統(tǒng)模式管理向信息管理的跨越式發(fā)展。 二、系統(tǒng)綜合集成,信息高度共享 醫(yī)院數(shù)字化的核心是病人信息的共享,以數(shù)據(jù)庫(kù)為中心實(shí)現(xiàn)病人信息的無(wú)紙化和無(wú)膠片化。數(shù)字化管理徹底改變了傳統(tǒng)作業(yè)流程,為醫(yī)務(wù)人員提供網(wǎng)絡(luò)化工作模式提高了工作效率,方便了患者；同時(shí),管理者可以通過(guò)網(wǎng)絡(luò)及時(shí)獲取各種醫(yī)療信息.及時(shí)做出科學(xué)決策。 三、醫(yī)療行為規(guī)范,環(huán)節(jié)監(jiān)控到位 醫(yī)院信息系統(tǒng)的應(yīng)用,明顯改變了手工操作模式下的工作隨意性大、質(zhì)量監(jiān)督難的問(wèn)題[53],為醫(yī)護(hù)人員提高了規(guī)范的業(yè)務(wù)操作平臺(tái)和有效的質(zhì)量管理平臺(tái)。①電子醫(yī)療文書(shū)取代了過(guò)去的手寫(xiě)醫(yī)療文書(shū)。格式規(guī)范,頁(yè)面整齊,項(xiàng)目齊全,保留了所有修改痕跡,且可加蓋電子印章保護(hù)。②規(guī)范醫(yī)療行為和過(guò)程,減少醫(yī)療中的隨意性和不確定性。在醫(yī)療過(guò)程中,存在大量的操作、時(shí)限、審批、檢診、查對(duì)的監(jiān)控環(huán)節(jié),將上述規(guī)范和要求設(shè)置在信息系統(tǒng)中,醫(yī)務(wù)人員在使用信息系統(tǒng)時(shí),實(shí)時(shí)受到監(jiān)控和提示,確保診療過(guò)程的規(guī)范和準(zhǔn)確。③通過(guò)合理用藥,藥物不良反應(yīng)、院內(nèi)感染、危重疾病等項(xiàng)目的在線(xiàn)監(jiān)控,及時(shí)提示、預(yù)警和控制診療過(guò)程可能出現(xiàn)的質(zhì)量問(wèn)題。④信息系統(tǒng)的應(yīng)用大大減少了人工操作環(huán)節(jié),同時(shí)采用數(shù)字標(biāo)識(shí)和識(shí)別技術(shù),以數(shù)據(jù)的自動(dòng)識(shí)別、采集和處理替代了過(guò)去人工操作容易出錯(cuò)的環(huán)節(jié)。 四、電子病歷應(yīng)用,提升智慧水平 電子病歷系統(tǒng)把原先在分散在不同信息系統(tǒng)的診療系統(tǒng)以病人為索引進(jìn)行整合,形成病人的電子病歷,為醫(yī)師檢索、調(diào)閱、使用、歸檔病人診療信息提供有效手段,使醫(yī)師能夠全面了解和掌握病人的病情,以便做出正確的診斷和處置。電子病歷系統(tǒng)比較完整的保存了病人的診療數(shù)據(jù),除了用于病人的治療外,這些數(shù)據(jù)的積累形成了一個(gè)大型的醫(yī)療知識(shí)庫(kù),包含了病人和疾病的客觀(guān)資料以及醫(yī)務(wù)人員在診治病人中的知識(shí)和智慧。通過(guò)數(shù)據(jù)分析、挖掘等工具,發(fā)現(xiàn)和歸納出診療規(guī)律,指導(dǎo)和輔助臨床診療活動(dòng)。電子病歷還為居民健康檔案提供居民在醫(yī)院住院、門(mén)診或體檢期間的診療數(shù)據(jù),是居民健康檔案的重要組成部分。 研究創(chuàng)新： 設(shè)計(jì)了數(shù)字化智慧醫(yī)療病區(qū)平臺(tái)體系架構(gòu),創(chuàng)新了數(shù)字化病區(qū)診療服務(wù)模式,應(yīng)用了“以患者為中心”的安全便捷高效的診療流程。構(gòu)建了數(shù)字化智慧醫(yī)療病區(qū)質(zhì)量管控體系,顯著提高了病區(qū)醫(yī)療質(zhì)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.

【學(xué)位授予單位】：南方醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R197.32

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本文編號(hào)：1430782