發(fā)布時間：2018-06-01 22:41

  本文選題：電子病歷 + 應用評價��； 參考：《東南大學》2017年碩士論文

【摘要】：研究背景和目的:近年中央和地方各級政府大力加強對醫(yī)療信息化的政策支持力度和財政投入,形成醫(yī)療衛(wèi)生信息化建設前所未有的良好局面,大型醫(yī)院已基本建立HIS、PACS、LIS、EHR以及醫(yī)院集成平臺、區(qū)域衛(wèi)生信息平臺、遠程醫(yī)療平臺等各種信息系統(tǒng),衛(wèi)生行業(yè)正在進入全面信息化的發(fā)展期,電子病歷系統(tǒng)成為建設核心,如何評價電子病歷要求正在成為重要問題。中美兩國分別在2010年和2009年提出電子病歷應用評價標準,本研究旨在從標準內(nèi)容和標準推廣兩個方面進行比較研究,一是對比中美兩個評價標準內(nèi)容有多少差異,二是歷經(jīng)數(shù)年發(fā)展,兩個標準在實踐中推廣效果表現(xiàn)如何,存在哪些影響因素,哪些政策可以相互借鑒,對中國電子病歷應用評價提出改進建議。研究方法:本文以文獻研究、比較研究和專家訪談為主要研究方法。文獻研究上以2006年1月1日到2016年2月28日為時間界限,從ELsevier、Springer-link、Pubmed、EBSCO、中國知網(wǎng)、萬方數(shù)據(jù)庫、維普科技文獻六個文獻庫采用主題詞檢索方式進行文獻檢索,在文獻閱讀基礎上手工補充文獻。在文獻研究基礎上,對美國《Electronic Health Record Incentive Program》(電子病歷激勵計劃中的"有效使用"標準)和中國《電子病歷系統(tǒng)功能應用水平分級評價方法和標準》的評價標準、評價方法、評價程序進行橫向比較法研究,分析對比美國和中國兩國在電子病歷評價方面的差異,歸納和總結(jié)相關問題和解決辦法進行專家訪談,評估美國標準與中國標準的等級對應關系,并用肯德爾和諧系數(shù)進行一致性檢驗。最后借鑒結(jié)構(gòu)-過程-結(jié)果模型,分組織體系、過程管理、政策效果三個部分對中美兩國電子病歷應用標準的政策推廣進行系統(tǒng)性比較研究,通過兩國醫(yī)院對評價標準的采用率來對比評價標準在政策實踐中的推廣效果,從組織體系、過程管理分別分析效果差異的影響因素,結(jié)合我國電子病歷發(fā)展現(xiàn)狀,為我國電子病歷推廣提供政策參考意見。結(jié)果:1、美國電子病歷"有效使用"中針對醫(yī)院的評價項目在階段1有24個、階段2有22個,分別與中國電子病歷應用水平分級的37個評價項目橫向?qū)Ρ?階段1和階段2中分別有15項和12項與中國標準的評價項目不同級別相對應,中國標準中有17項是關注醫(yī)院內(nèi)部流程的評價項目,美國標準中沒有對應項。2、通過專家訪談和調(diào)查反饋顯示,美國標準階段1和階段2的評價要求與中國電子病歷應用水平分級的第4級最為相近,專家評價肯德爾協(xié)調(diào)系數(shù)分別為0.870 和 0.888(P0.05)。3、從政策產(chǎn)出效果對比分析,在相同的五年時間中,參與美國電子病歷"有效使用"標準的醫(yī)院采用率為85%,遠高于中國電子病歷應用分級評價標準39%的參與采用率(P0.01)。4、從組織體系對比分析,美國通過ONC、CMS、HITSP三家機構(gòu)分別從戰(zhàn)略方面、準入機制、標準協(xié)同、評價核定等方面共同推進電子病歷應用評價工作,同時提供人員培訓、示范社區(qū)、區(qū)域支持等諸多措施配套推進,可以看出美國電子病歷應用評價的組織體系更為成熟;中國目前僅有電子病歷試點辦公室負責評價核定工作,缺乏進行頂層設計的組織保障、也缺少標準協(xié)同機構(gòu),整體組織體系相對薄弱,配套措施較少。5、從過程管理對比分析,美國標準已經(jīng)進行三次更新,并提供電子病歷激勵計劃,通過經(jīng)濟刺激進行鼓勵使用,為標準推廣提供更持久動力;中國標準自2010年頒布之后至今尚未進行過更新,也缺乏相關激勵反饋機制。結(jié)論:1、中國電子病歷應用評價標準覆蓋面遠低于美國類似標準的原因可能有:1)組織機構(gòu)不完善;2)缺少系統(tǒng)性配套措施;3)缺少經(jīng)濟激勵措施。2、中國的政策制定要充分認識電子病歷推廣的復雜性和長期性。美國在強力的政策支持、完善的組織機構(gòu)、諸多配套行動的支持下,其推廣計劃仍多次受挫,被迫延期,在中國醫(yī)療機構(gòu)尚且不具備諸多有利條件的情況下,制定電子病歷以及健康大數(shù)據(jù)推廣政策更需要對此有清晰的認識。3、要充分關注電子病歷推廣的頂層戰(zhàn)略設計,不能僅僅關注標準內(nèi)容,更需明確電子病歷應用目的,制定長期計劃進行引導,重視績效產(chǎn)出表現(xiàn),在推動大型醫(yī)療機構(gòu)有效使用電子病歷同時,更需要促進中小醫(yī)院和診所對電子病歷應用的關注。4、評價標準需要關注整個體系的建設,形成循證決策,不斷調(diào)整,促進標準能根據(jù)不同利益方需求和時代發(fā)展不斷進化更新,保持標準的有效性和前瞻性。5、可借鑒美國經(jīng)驗,利用醫(yī)保資金補償作為經(jīng)濟激勵措施,促進利益相關各方的協(xié)同,提升效率使社會整體能獲得更好收益,也為評價標準發(fā)展提供更持久的發(fā)展動力。
[Abstract]:Research background and purpose: in recent years, the central and local governments at all levels have strengthened the policy support and financial input to medical information, and formed an unprecedented good situation in the construction of medical and health information. The large hospitals have basically established HIS, PACS, LIS, EHR and the platform of hospital collection, regional health information platform, telemedicine platform, etc. All kinds of information systems, the health industry is entering the development period of comprehensive information. The electronic medical record system has become the core of the construction. How to evaluate the requirements of the electronic medical record is becoming an important problem. China and the United States put forward the evaluation standard of the application of electronic medical records in 2010 and 2009 respectively. This study aims to promote two aspects from the standard content and standard. Comparison study, one is to compare the differences between the two evaluation standards of China and the United States, two is the development of the past several years, the two standards in practice how to promote the effectiveness of the performance, which factors, which policies can learn from each other, and put forward suggestions for the evaluation of the application of electronic medical records in China. Research and expert interview are the main research methods. In the literature study, from January 1, 2006 to February 28, 2016, ELsevier, Springer-link, Pubmed, EBSCO, Chinese knowledge network, Wanfang database, and VP science and technology literature are retrieved by subject words retrieval methods, and the manual supplement on the basis of literature reading. On the basis of literature research, the (the "effective use" standard in the electronic medical record incentive plan) and the evaluation criteria for the evaluation method and standard of the functional application level of the electronic medical records system, the evaluation method and the evaluation procedure were studied laterally, and the analysis and comparison of the United States and the United States were made. The differences in the evaluation of electronic medical records in China, induction and summary of related problems and solutions are interviewed by experts, and the corresponding relationship between the United States and China standards is evaluated, and the consistency test is carried out with the Kendall harmony coefficient. Finally, the structure process result model, the organization system, the process management, and the policy effect are three. A systematic comparative study of the policy promotion of the standard for the application of electronic medical records in China and the United States is systematically compared. Through the comparison of the adoption rate of the evaluation standards of the two hospitals in the two countries, the effectiveness of the evaluation standards in the policy practice is compared, and the impact factors of the difference in the effect are analyzed from the organizational system and process management respectively, and the status of the development of the electronic medical records in China is combined. China's electronic medical record promotion provides policy reference. Results: 1, the United States electronic medical records "effective use" of the hospital evaluation projects in stage 1 have 24, stage 2, 22, respectively, and the Chinese electronic medical record application level of the 37 evaluation items in the horizontal comparison, stage 1 and stage 2, 15 and 12 items with China standard evaluation respectively. 17 of the Chinese standards are concerned with the evaluation of the internal process of the hospital. There is no corresponding item.2 in the United States standard. Through expert interview and feedback, the evaluation of the standard 1 and stage 2 in the United States is the most similar to the level of the level of the application level of the Chinese electronic medical record. The expert evaluation of the Kendall Association The adjustment coefficients are 0.870 and 0.888 (P0.05).3 respectively. From the comparison and analysis of the effect of policy output, in the same five years, the adoption rate of the "effective use" standard of the American electronic medical record is 85%, far higher than the participation rate (P0.01).4 of the Chinese Electronic medical record application grading evaluation standard 39%, from the organizational system comparison and analysis, the United States passes the ONC The three institutions of CMS and HITSP, respectively, promote the application and evaluation of electronic medical records from the aspects of strategy, access mechanism, standard synergy, evaluation and verification, and provide personnel training, demonstration community, regional support and many other measures. It can be seen that the organization system of the evaluation of the application of electronic medical records in the United States is more mature; at present, China is only the only one. The pilot office of the electronic medical record is responsible for the evaluation of the work, the lack of organizational guarantee for the top level design, the lack of standard coordination institutions, the relatively weak overall organization system and the less supporting measures.5. The United States standards have been updated three times from the process management comparison and analysis, and the electronic medical record incentive plan is provided through the economic stimulus. Encourage use, provide more lasting power for standard extension; China standard has not been updated since its promulgation in 2010 and lack of relevant incentive feedback mechanism. Conclusion: 1, the reason that the coverage of the evaluation standard of the application of Chinese electronic medical records is far below the similar standards in the United States may be: 1) the organization is not perfect; 2) lack of systematic supporting measures. 3) the lack of economic incentives.2, China's policy formulation should fully recognize the complexity and long term of the promotion of electronic medical records. With the support of strong policy support, perfect organization, and many supporting actions, the promotion plan of the United States is still frustrated and delayed, and there are still no favorable conditions in Chinese medical institutions. In the case of an electronic medical record and a large health data promotion policy, we need to have a clear understanding of the.3. We should pay full attention to the top-level strategic design of the electronic medical record promotion. We should not only pay attention to the standard content, but also need to clarify the purpose of the application of the electronic medical record, make the long-term plan guidance, pay attention to the performance output and promote the large medical machine. The effective use of electronic medical records should also promote the attention of small and medium hospitals and clinics to the application of electronic medical records (.4). The evaluation standards need to pay attention to the construction of the whole system, form evidence-based decision-making, constantly adjust, and promote the continuous evolution of standards according to the needs of different interests and the development of the times, and maintain the validity and forward-looking.5 of the standard. Using the experience of the United States for reference, using the medical insurance fund compensation as an economic incentive measure, promote the synergy of the stakeholders, improve the efficiency to make the whole society gain better income, and provide a more lasting impetus for the development of the evaluation standard.
【學位授予單位】：東南大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R197.323

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