本文關(guān)鍵詞：某三級(jí)醫(yī)院臨床信息系統(tǒng)建設(shè)及應(yīng)用研究，由筆耕文化傳播整理發(fā)布。

        研究背景醫(yī)院信息化建設(shè)在保障與支持醫(yī)療體制改革順利進(jìn)行和保證醫(yī)院可持續(xù)發(fā)展等方面的作用日益顯著,從衛(wèi)生部頒布的《三級(jí)綜合醫(yī)院評(píng)審標(biāo)準(zhǔn)實(shí)施細(xì)則》可以看出,信息化所占比重最大。在其設(shè)置的378項(xiàng)評(píng)審內(nèi)容與監(jiān)測(cè)指標(biāo)中,與信息化直接相關(guān)或間接相關(guān)的條款最多,內(nèi)容覆蓋門診就醫(yī)、住院診療、安全管控、院務(wù)保障及信息公開等各個(gè)層次,觸及業(yè)務(wù)流程、醫(yī)療質(zhì)量、工作效率、服務(wù)監(jiān)督、綜合管控等各個(gè)環(huán)節(jié)。信息化已與醫(yī)院全面建設(shè)與發(fā)展息息相關(guān),并為醫(yī)院等級(jí)評(píng)審及醫(yī)院決策提供有力的支撐。醫(yī)院等級(jí)評(píng)審對(duì)三級(jí)醫(yī)院臨床信息系統(tǒng)提出了明確要求,即應(yīng)建立電子病歷系統(tǒng)和至少12種臨床路徑,因此開展醫(yī)院臨床信息系統(tǒng)建設(shè)研究具有重要的現(xiàn)實(shí)意義。研究目的本文通過醫(yī)院臨床信息系統(tǒng)建設(shè)方法及應(yīng)用研究,以探討提高醫(yī)療質(zhì)量與效率的方式方法,著力探討信息化實(shí)現(xiàn)醫(yī)療業(yè)務(wù)流程的優(yōu)化與創(chuàng)新的途徑和手段,探索依托信息化加強(qiáng)臨床診療風(fēng)險(xiǎn)的監(jiān)測(cè)與控制的模式和機(jī)制,針對(duì)臨沂市人民醫(yī)院的信息系統(tǒng)起步較晚、信息系統(tǒng)的建設(shè)已經(jīng)跟不上醫(yī)院的發(fā)展的具體情況,利用三級(jí)醫(yī)院評(píng)審的時(shí)機(jī),醫(yī)院?jiǎn)?dòng)了新一輪信息系統(tǒng)建設(shè),研究如何圍繞臨床應(yīng)用為核心,推進(jìn)醫(yī)院臨床信息系統(tǒng)的中長(zhǎng)期建設(shè)。研究方法文獻(xiàn)調(diào)研通過查閱與醫(yī)院臨床信息系統(tǒng)建設(shè)方法研究有關(guān)的文獻(xiàn)、資料及書籍,了解到國(guó)內(nèi)外醫(yī)院臨床信息系統(tǒng)發(fā)展進(jìn)程及研究現(xiàn)狀,根據(jù)以前研究基礎(chǔ)設(shè)計(jì)了臨床路徑應(yīng)用調(diào)研基準(zhǔn),從而為本文的調(diào)查研究提供一定的參考依據(jù)。定性訪談法我們對(duì)科室臨床醫(yī)生進(jìn)行了深度訪談,內(nèi)容包括目前臨床信息系統(tǒng)建設(shè)和應(yīng)用狀況以及應(yīng)用取得的效果,在實(shí)地調(diào)查以及課題開展中,注重咨詢醫(yī)院一線工作人員和相關(guān)領(lǐng)域?qū)＜医淌诘囊庖姾徒ㄗh,使研究更加科學(xué)。主要結(jié)果信息化與醫(yī)院全面建設(shè)與發(fā)展息息相關(guān),并為各項(xiàng)評(píng)審及醫(yī)院決策提供有力的支撐。因此醫(yī)院要轉(zhuǎn)變觀念,從根本上改變?yōu)閼?yīng)付評(píng)審工作而做信息化的想法,應(yīng)該按標(biāo)準(zhǔn)建設(shè)醫(yī)院信息化,應(yīng)按標(biāo)準(zhǔn)管理醫(yī)院信息化,減少隨意性和盲目性,首先應(yīng)明確臨床信息系統(tǒng)建設(shè)的范圍和內(nèi)容。臨床信息系統(tǒng)的建設(shè)是一個(gè)復(fù)雜的過程,不是對(duì)各子系統(tǒng)進(jìn)行簡(jiǎn)單的累加過程,首先要對(duì)已有的信息系統(tǒng)進(jìn)行分析,理清各個(gè)系統(tǒng)之間的關(guān)系；其次分析已有的面向臨床的信息子系統(tǒng),明確這些子系統(tǒng)在臨床應(yīng)用方面的缺陷；最后構(gòu)建符合醫(yī)院長(zhǎng)期持續(xù)發(fā)展的信息系統(tǒng)基礎(chǔ)架構(gòu)。通過調(diào)查分析的結(jié)果,我們可以得出醫(yī)院臨床信息系統(tǒng)的建設(shè)路徑,進(jìn)而明確各個(gè)子系統(tǒng)需要改造的工作量。臨床信息系統(tǒng)建設(shè)的路徑應(yīng)首先以CPOE為核心推動(dòng)醫(yī)療流程的建設(shè),其次利用CPOE驅(qū)動(dòng)電子病歷文書系統(tǒng),最后在CPOE和電子病歷文書的基礎(chǔ)上創(chuàng)建臨床路徑系統(tǒng),從而實(shí)現(xiàn)臨床數(shù)據(jù)倉庫(CDR),最終為醫(yī)院信息平臺(tái)的建設(shè)奠定基礎(chǔ)。結(jié)論與建議本文對(duì)臨床信息系統(tǒng)子系統(tǒng)的設(shè)計(jì)和建設(shè)方法進(jìn)行論述,并給出了當(dāng)前形勢(shì)下適合醫(yī)院發(fā)展的臨床信息系統(tǒng)的建設(shè)范圍和方法。推進(jìn)臨床信息系統(tǒng)建設(shè)是醫(yī)院信息化的長(zhǎng)期目標(biāo),應(yīng)充分認(rèn)識(shí)到在醫(yī)院現(xiàn)有信息系統(tǒng)現(xiàn)狀,應(yīng)在現(xiàn)有信息系統(tǒng)的基礎(chǔ)上有序可控發(fā)展。在臨床信息系統(tǒng)的建設(shè)過程中必須兼顧短期目標(biāo)和中長(zhǎng)期目標(biāo),不能偏重于短期目標(biāo)而忽視了醫(yī)院信息化發(fā)展的中長(zhǎng)期規(guī)劃,造成信息系統(tǒng)推倒重來；也不能偏重于中長(zhǎng)期規(guī)劃而忽視三級(jí)醫(yī)院評(píng)審的短期緊急目標(biāo),造成三級(jí)醫(yī)院評(píng)審遇到巨大風(fēng)險(xiǎn),通過合理的軟件技術(shù),既能滿足三級(jí)醫(yī)院等級(jí)評(píng)審工作要求,又能兼顧醫(yī)院信息系統(tǒng)的中長(zhǎng)期發(fā)展規(guī)劃。臨床信息系統(tǒng)的建設(shè)需要臨床各業(yè)務(wù)科室的配合才可以成功,這與普通的信息系統(tǒng)的建設(shè)具有明顯的區(qū)別,由于臨床信息系統(tǒng)涉及的科室和人員廣泛,其項(xiàng)目管理變得異常復(fù)雜和艱難。因此,信息部門應(yīng)該對(duì)臨床信息系統(tǒng)的推廣有足夠的思想準(zhǔn)備。借助于三級(jí)評(píng)審,臨沂市人民醫(yī)院?jiǎn)?dòng)了臨床信息系統(tǒng)的建設(shè),這個(gè)項(xiàng)目對(duì)于信息部門還是臨床業(yè)務(wù)部門都是一個(gè)考驗(yàn)。經(jīng)過充分的溝通,臨床信息系統(tǒng)的建設(shè)方案已經(jīng)明確,計(jì)劃經(jīng)過2年的項(xiàng)目建設(shè)和推廣,借助于本課題的研究,以下方面在實(shí)施過程依然需要不斷改進(jìn)和細(xì)化·臨床信息系統(tǒng)所依托的基礎(chǔ)設(shè)施的建設(shè),重點(diǎn)是基于集成平臺(tái)的分層設(shè)計(jì),需要在下一步的建設(shè)中進(jìn)一步完善�！ら]環(huán)CPOE所包含的移動(dòng)醫(yī)護(hù)功能還需要進(jìn)一步研究；·臨床路徑的知識(shí)庫建設(shè)尚需要與標(biāo)準(zhǔn)進(jìn)行對(duì)接；·CDR建設(shè)的內(nèi)容還需要明確。由于臨床信息系統(tǒng)的建設(shè)是一個(gè)長(zhǎng)期的過程,從部分已經(jīng)上線的系統(tǒng)來看,已經(jīng)取得了短期的效益,改變了臨床科室對(duì)于信息系統(tǒng)的看法,使得醫(yī)院管理層和臨床科室已經(jīng)具備了信息系統(tǒng)改進(jìn)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.

某三級(jí)醫(yī)院臨床信息系統(tǒng)建設(shè)及應(yīng)用研究

中文摘要6-9ABSTRACT9-12符號(hào)說明13-14一、前言14-18二、醫(yī)院臨床信息系統(tǒng)建設(shè)18-29    2.1 醫(yī)院信息化現(xiàn)狀分析18-22    2.2 醫(yī)院臨床信息系統(tǒng)建設(shè)路徑分析22-29三、電子病歷系統(tǒng)29-32    3.1 電子病歷簡(jiǎn)述29-30    3.2 電子病歷發(fā)展30-31    3.3 電子病歷相關(guān)規(guī)范31-32    3.4 電子病歷發(fā)展趨勢(shì)32四、CPOE和臨床路徑32-38    4.1 CPOE和臨床路徑的現(xiàn)狀分析33    4.2 實(shí)施方法33-35    4.3 應(yīng)用效果35-36    4.4 知識(shí)庫建立36-37    4.5 結(jié)論37-38五、電子病歷文書38-44    5.1 現(xiàn)狀38-39    5.2 結(jié)構(gòu)化數(shù)據(jù)存儲(chǔ)39-41    5.3 電子病歷文書的集成41-42    5.4 動(dòng)態(tài)模板42-43    5.5 病歷質(zhì)控管理43-44    5.6 結(jié)論44六、醫(yī)院感染管理44-49    6.1 概述44-45    6.2 相關(guān)研究45    6.3 實(shí)現(xiàn)方法45-48    6.4 應(yīng)用效果48    6.5 結(jié)論48-49七、小結(jié)和展望49-51    7.1 臨床信息子系統(tǒng)的建設(shè)路徑49    7.2 臨床信息系統(tǒng)建設(shè)的范圍和內(nèi)容49-51參考文獻(xiàn)51-55致謝55-56攻讀碩士學(xué)位期間發(fā)表論文情況56-57附件57

  本文關(guān)鍵詞：某三級(jí)醫(yī)院臨床信息系統(tǒng)建設(shè)及應(yīng)用研究，由筆耕文化傳播整理發(fā)布。