病歷以及電子病歷介紹病歷以及電子病歷介紹

第24章電子病歷第一節(jié)概述1.病歷簡(jiǎn)史什么叫病歷？病人一次就診（門診、住院）的相關(guān)記錄。醫(yī)務(wù)人員在醫(yī)療活動(dòng)過程中形成得文字、符號(hào)、圖表、影像、切片等資料得總和病歷是求醫(yī)病人的健康和疾病狀態(tài)記錄，由醫(yī)生、護(hù)士記載，包括與疾病過程有關(guān)的臨床發(fā)現(xiàn)、診斷、檢驗(yàn)結(jié)果和治療信息。門急（診）病歷：住院病歷：首頁(yè)、病程、醫(yī)囑、檢查檢驗(yàn)結(jié)果和生理體征記錄。使用病歷的目的支持病人醫(yī)療護(hù)理。（是評(píng)估、決策醫(yī)護(hù)工作的資源,醫(yī)護(hù)者共享的資源）醫(yī)療行為的合法報(bào)告。支持醫(yī)療研究（臨床、流行病研究,評(píng)定醫(yī)護(hù)質(zhì)量,藥品售后監(jiān)督）。臨床教學(xué)。醫(yī)療管理和服務(wù)（支持付帳和醫(yī)保,支持費(fèi)用管理等）。（2）病歷簡(jiǎn)史1）公元前5世紀(jì)希波克拉底就提倡病歷需實(shí)現(xiàn)兩個(gè)目標(biāo):準(zhǔn)確反映疾病過程、指出疾病的可能原因。著重疾病的描述。當(dāng)時(shí)記載“Apollonius長(zhǎng)期生病,但未臥床。腹部腫脹肝部長(zhǎng)期疼痛,近期出現(xiàn)黃疸和胃腸脹氣（描述從求醫(yī)前開始）。有一天,吃飯飲酒過量,過后感覺很熱,上床睡覺,并喝了太多的奶。這種不好的飲食方式,使他的病情加重（描述求醫(yī)原因）。發(fā)熱進(jìn)一步加劇,腸胃無食物,尿少,失眠,腹部鼓脹,十分口渴,自語(yǔ)……臥床14天后,發(fā)高熱,極度神志不清,喊叫,痛苦,恍惚。接著平靜下來,開始昏迷……大約24天稍感舒服。病人有一段清醒期,大約30天出現(xiàn)急性發(fā)熱,大量稀便,手足發(fā)冷,神志恍惚,不能說話。第34天病人死亡?！惫?世紀(jì)希波克拉底描述的病歷原文2）19世紀(jì)初,隨著聽診器的發(fā)明及其他醫(yī)療儀器的發(fā)展,擴(kuò)展了醫(yī)生的感官,從而病歷也從病人或家屬的敘述擴(kuò)展到醫(yī)生、護(hù)士的發(fā)現(xiàn)。19世紀(jì)末,美國(guó)外科醫(yī)生威廉,在自己創(chuàng)辦的診所中要求每位醫(yī)生用帳簿按年月順序記錄所有病人的就診情況。20世紀(jì)初（1907年）創(chuàng)立了以一個(gè)病人為一個(gè)文件夾的以病人為中心的病歷,并在1920年要求必須在病歷中記錄一組規(guī)定的最基本數(shù)據(jù)。它是現(xiàn)代病歷的基本框架。3）20世紀(jì)60年代,Weed改進(jìn)了病歷的機(jī)構(gòu),他提出以問題為中心的病歷結(jié)構(gòu)SOAP。指定幾個(gè)問題,每個(gè)問題都以S（主觀類,如主訴）O（客觀類,臨床發(fā)現(xiàn)）A（評(píng)估類,檢驗(yàn)結(jié)果、診斷）P（計(jì)劃類,治療和處理）單獨(dú)表述。病歷更標(biāo)準(zhǔn)化、有序化,且更能反映醫(yī)護(hù)人員描述疾病的思路。但這種病歷需要通過加強(qiáng)訓(xùn)練才能運(yùn)用。2.病歷描述的格式1）以時(shí)間為順序的類型1996年2月21日呼吸短促，咳嗽，發(fā)熱。大便顏色深黑。檢查:血壓150/90mmHg，脈搏95次/min，體溫39.3度。肺部有干啰音，腹部無壓痛。目前藥物療法是每日阿司匹林64mg?？赡苁侵夤苎祝赡苓€并發(fā)心臟失代償。阿司匹林可能造成出血。紅細(xì)胞沉降率（ESR）25mm/h,血紅蛋白（Hb）78g/L，大便隱血＋。胸透:無肺不張現(xiàn)象，輕微心臟失代償癥狀。藥物療法:阿司匹林膠囊500mg,每日2次，阿司匹林減量至32mg。1996年3月4日不再咳嗽，輕微呼吸短促，大便顏色正常。檢查:輕微干羅音，血壓160/95mmHg,脈搏82次/min。每日服用阿司匹林32mg。Hg 82g/L,大便隱血測(cè)試。2）以信息源為中心類型就診1996年2月21日:呼吸短促，咳嗽，發(fā)熱。大便顏色深黑。檢查:血壓150/90mmHg，脈搏95次/min，體溫39.3度。肺部有干啰音，腹部無壓痛。目前藥物療法是每日阿司匹林64mg?？赡芑技毙灾夤苎?，伴有心率失常。消化道出血可能是阿司匹林所致。藥物療法:阿司匹林膠囊500mg,每日2次，阿司匹林減量至32mg。1996年3月4日:不再咳嗽，輕微呼吸短促，大便顏色正常。檢查:輕微干啰音，血壓160/95mmHg,脈搏82次/min。每日服用阿司匹林32mg。Hg 82g/L?；?yàn)結(jié)果1996年2月21日: 紅細(xì)胞沉降率（ESR）25mm/h,血紅蛋白（Hb）78g/L，大便隱血＋。1996年3月4日:Hg 82g/L,大便隱血測(cè)試。X線檢查1996年2月21日:胸透無肺不張現(xiàn)象，輕微心率失常。3）以問題為中心類型問題1:急性支氣管炎1996年2月21日S:呼吸短促，咳嗽，發(fā)熱。O:血壓150/90mmHg，脈搏95次/min，體溫39.3度。肺部有干啰音，腹部無壓痛。ERS25mm/h。胸透無肺不張現(xiàn)象，輕微心率失常。A:急性支氣管炎。P:藥物療法:阿司匹林膠囊500mg,每日2次，阿司匹林減量至32mg。1996年3月4日S:不再咳嗽，輕微呼吸短促。O:檢查:輕微干啰音，脈搏82次/min。A:輕微支氣管炎。問題2:呼吸短促。1996年2月21日S:呼吸短促。O:血壓150/90mmHg，肺部有干啰音。無肺不張現(xiàn)象，輕微心率失常。A:輕微心率失常。1996年3月4日S:輕微呼吸短促。O:血壓160/95mmHg,脈搏82次/min。A:無呼吸困難。問題3:大便顏色深黑1996年2月21日S:大便顏色深黑。目前藥物治療每日阿司匹林64mgO:腹部無壓痛，直腸指撿未見初血，Hb 78b/LA::可能阿司匹林引起消化道初血。P:阿司匹林減量至32mg。1996年3月4日S:大便顏色正常。O:大便隱血檢查。A:無消化道出血癥狀。P:維持每日服用阿司匹林32mg。三種病歷格式比較:以時(shí)間順序?yàn)橹行牡牟v不利于分析病情的發(fā)展趨勢(shì)以Weed的SOAP格式表示的以問題為中心的病歷，雖然有較好的結(jié)構(gòu)，但因需經(jīng)較好的訓(xùn)練，只在臨床記錄中有人運(yùn)用。多數(shù)是混合型描述格式，往往以信息源為中心，并以時(shí)間先后為順序。2.紙質(zhì)病歷與電子病歷在沒有建立HIS的醫(yī)療機(jī)構(gòu)中，病歷通常手工書寫，以紙介質(zhì)保存，稱紙質(zhì)病歷。紙質(zhì)病歷存在的問題：保存分散，難以查找，容易丟失。內(nèi)容是自由文本形式，字跡可能不清，內(nèi)容可能不完整，意思可能模糊。科學(xué)分析時(shí)需要轉(zhuǎn)抄，容易出現(xiàn)潛在錯(cuò)誤。只能被動(dòng)地供醫(yī)生作決策參考，不能實(shí)現(xiàn)主動(dòng)提醒、警告或建議。（3）電子化病歷在醫(yī)療信息系統(tǒng)中病歷數(shù)據(jù)存儲(chǔ)在非紙的電子化介質(zhì)中稱電子化病歷。電子病歷（CPR、EMR）應(yīng)是電子化病歷的高級(jí)形式,是有關(guān)病人的健康和醫(yī)護(hù)情況的終身電子信息。是病人完整的、集成的信息。電子病歷不僅信息載體電子化、多媒體化,且提供超越紙質(zhì)病歷的服務(wù)功能。紙質(zhì)病歷與電子化病歷的各自優(yōu)點(diǎn):紙質(zhì)病歷 電子化病歷方便攜帶、報(bào)告形式自由、數(shù)據(jù)易于瀏覽、無須特殊訓(xùn)練、可同時(shí)訪問多處數(shù)據(jù)、易讀性、多種查詢方式、支持結(jié)構(gòu)化數(shù)據(jù)輸入、不像計(jì)算機(jī)那樣丟失數(shù)據(jù)。決策支持、支持其他數(shù)據(jù)分析、支持電子數(shù)據(jù)交換和共享。第二節(jié)

電子病歷的內(nèi)容一、電子病歷的概念 美國(guó)電子病歷協(xié)會(huì):電子病歷是用電子方式來保存?zhèn)€人終身健康狀況和保健信息。 美國(guó)國(guó)立醫(yī)學(xué)研究所:電子病歷是基于一個(gè)特定系統(tǒng)的電子化病人記錄，該系統(tǒng)提供用戶訪問完整正確的數(shù)據(jù)、警告、提示和臨床決策支持系統(tǒng)的能力。電子病歷是以電子化方式管理的有關(guān)個(gè)人終生健康狀態(tài)和醫(yī)療保健行為的信息,涉及病人信息的采集、存儲(chǔ)、傳輸、處理和利用。可在醫(yī)療中作為主要的信息源取代紙張病歷,提供超越紙張病歷的服務(wù),滿足所有的醫(yī)療、法律和管理需求電子病歷系統(tǒng)是指為人們提供各種醫(yī)療衛(wèi)生服務(wù)過程中采集、存儲(chǔ)、傳輸、提取和處理衛(wèi)生信息的計(jì)算機(jī)與通訊處理系統(tǒng),包括各種醫(yī)療知識(shí)獲取和輔助診斷決策等功能；電子病歷管理系統(tǒng),是指對(duì)形成之后的電子病歷進(jìn)行的相關(guān)的管理功能。電子化病歷的名稱:EHR 電子健康記錄(Electronic Health RecorEHCR 電子醫(yī)療保健記錄(Electronic HealthCare Record)EPR 電子病歷(Electronic Patient Record)CPR 計(jì)算機(jī)化的病人記錄(ComputerizedPatient Record)EMR 電子醫(yī)療記錄(Electronic Medical Reco它們的區(qū)別在于記錄的時(shí)間長(zhǎng)度及范圍。時(shí)間長(zhǎng)度EMR 和 EPR : 歷次就診或治療信息 (接近于ICU記錄)EHR:一生 (接近于健康檔案)范圍EMR: 基于醫(yī)療活動(dòng)EHR: 醫(yī)療摘要，以及非醫(yī)學(xué)因素ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.電子病歷目的紙質(zhì)病歷: 探索和發(fā)現(xiàn)問題信息的初級(jí)利用,最主要的受益人是病人和醫(yī)師電子病歷:解決問題信息的二次利用,更多人獲益ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.電子病歷不是電子化的紙質(zhì)病歷。因?yàn)槟壳暗募堎|(zhì)病歷收集的信息不能滿足電子病歷的二次利用。因此,電子病歷的設(shè)計(jì)更強(qiáng)調(diào)滿足二次利用的需求,如關(guān)于財(cái)務(wù)、政策和計(jì)劃、統(tǒng)計(jì)分析,醫(yī)療質(zhì)量認(rèn)證等方面的信息。ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.電子病歷的二次利用主要包括:醫(yī)治的合法性—提供醫(yī)療服務(wù)的證據(jù)；是否符合法律；反映醫(yī)師的能力。質(zhì)量管理—醫(yī)療服務(wù)質(zhì)量跟蹤研究；治療與操作的監(jiān)測(cè)。教育與培訓(xùn)。ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.研究—提出和評(píng)價(jià)新的疾病診斷、預(yù)防與治療、流行病學(xué)研究以及人群健康分析方法。公共衛(wèi)生—高質(zhì)量的信息可使我們對(duì)已有的和潛在的危害公眾健康的因素進(jìn)行及時(shí)有效的管理和決策。ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.政策制定—衛(wèi)生統(tǒng)計(jì)分析,趨勢(shì)分析,病例組合分析。衛(wèi)生服務(wù)管理—衛(wèi)生資源的分配與管理,成本管理,報(bào)告及出版物,營(yíng)銷戰(zhàn)略,企業(yè)風(fēng)險(xiǎn)管理。結(jié)算/財(cái)務(wù)/費(fèi)用補(bǔ)償—保險(xiǎn)機(jī)構(gòu)；政府機(jī)構(gòu)；基金組織。ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.電子病歷特征:（1）真正以病人為中心，不僅包含病人的自身信息，而且要向所有參與醫(yī)療保健活動(dòng)的人提供相關(guān)信息，如社區(qū)保健、急診服務(wù)、遠(yuǎn)程醫(yī)療等。這一點(diǎn)不同于以醫(yī)療機(jī)構(gòu)為中心的歷次就診或治療信息記錄（門診或住院病歷）。ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.（2）包含的信息:觀測(cè)結(jié)果-已經(jīng)發(fā)生了什么處置-決定應(yīng)該做些什么保健計(jì)劃-將來應(yīng)該做些什么ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.（3）電子病歷的概括水平具有廣泛意義,也就是說,一些專門的信息,比如圖像,臨床指南或支持決策的方法都不是電子病歷本身特定的組成部分；應(yīng)該能夠在標(biāo)準(zhǔn)的交互界面為其它專門系統(tǒng)提供接口。ThisrepresentsouroneNetvision.Asacompany,wearecommittedtoprovidingsolutionstoyourbusinessproblemsbasedonthefulfillmentofthisstrategicframework.SinceweannouncedoneNetin1999,wehavebeenworkingtoidentifyanddevelopthetechnologies,productsandsolutionsuitesthatmakethevisionarealityforourcustomers.OneNetbringsyouclosertoaworldwherenetworksofalltypesworktogetherseamlessly,soyoucanconnectemployees,customers,suppliersandpartnersacrossorganizationalboundaries–andgivethemfaster,easierandmoresecureaccesstoalltheinformationandresourcestheyneed,whenandwheretheyneedit.AndourfulfillmentoftheoneNetstrategicframeworktranslatesdirectlyintobusinesssolutionsthatoffermoreopportunity,higherROIandcloser,moreproductiverelationshipswithyouandeveryonewhomatterstoyourbusiness.Let’stakeabrieftourofoneNettohelpsetthecontextforourdiscussiontoday.Startinginthecenter,ourNgageteamsemployprovenmethodologiesandexpertise,training,andsupportatalllevelsofyourorganizationtofacilitatethedesign,developmentanddeploymentofsecure,scalablebusinesssolutions.NovellexteNd,ourintegrateddevelopmentenvironmentforthecreationofWebservices-basedsolutionshelptransformrigid“silo”applicationsintopersonalized,standards-based,process-drivensecureWebsolutions.NovellNsure,oursecureidentitymanagementsolutionsfamily,deliversyourenterpriseresourcesandbusinessinformationbasedonwhopeopleareandwhattheyneed,wherevertheyneedit.NovellNterprise,ourcrossplatformnetworkservicessuites,addinvaluablecapabilitiestoallkindsofmixednetworksanddiverseinfrastructures.Nterprisesolutionsaretheembodimentofthisphilosophy.Wewilldeliverandsupporttheservicesontheplatformsourcustomersandthemarketdemand.Todayandintheforeseeablefuture,LinuxrunningonIntelistheplatformthemarketandourcustomersaredemanding.是診斷和其它檢驗(yàn)數(shù)據(jù)的“數(shù)據(jù)池”。為決策支持、醫(yī)學(xué)研究、衛(wèi)生行政,統(tǒng)計(jì)機(jī)構(gòu)及其它實(shí)體提供臨床信息。電子病歷是一個(gè)長(zhǎng)期的,關(guān)于病人將要發(fā)生什么或?qū)⒁獮椴∪俗鍪裁吹男畔⒎e累。二、電子病歷內(nèi)容靜態(tài)信息:紙質(zhì)病歷的全部信息。動(dòng)態(tài)信息:疾病發(fā)展過程中產(chǎn)生。門急癥電子病歷住院電子病歷個(gè)人電子病歷社區(qū)電子病歷遠(yuǎn)程醫(yī)療電子病歷第三節(jié)電子病歷的實(shí)現(xiàn)一、電子病歷相關(guān)技術(shù)數(shù)據(jù)庫(kù)與數(shù)據(jù)庫(kù)管理系統(tǒng)通信與網(wǎng)絡(luò)技術(shù)數(shù)據(jù)交換技術(shù)與術(shù)語(yǔ)標(biāo)準(zhǔn)安全技術(shù)數(shù)據(jù)挖掘技術(shù)圖像處理技術(shù)與其它系統(tǒng)集成的接口技術(shù)二、電子病歷的編碼及標(biāo)準(zhǔn)化(一)HL7醫(yī)院電子信息交換標(biāo)準(zhǔn):HL73.0版結(jié)合了XML病歷信息分三級(jí)結(jié)構(gòu):描述病歷頭部信息一級(jí)結(jié)構(gòu)描述病歷各組成節(jié)二級(jí)結(jié)構(gòu)描述具體內(nèi)容三級(jí)結(jié)構(gòu)（二）DICOM3.0－醫(yī)學(xué)數(shù)字化影像通信標(biāo)準(zhǔn)（三）HIPAA－安全標(biāo)準(zhǔn)HIPAA美國(guó)健康保險(xiǎn)及責(zé)任法案（四）ASTM相關(guān)標(biāo)準(zhǔn)美國(guó)材料與實(shí)驗(yàn)協(xié)會(huì)E3.11.E1238-94臨床與化驗(yàn)檢驗(yàn)信息交換的標(biāo)準(zhǔn)三、EPR模型的結(jié)構(gòu)化符合《病歷書寫暫行規(guī)定》 不同科室，病歷內(nèi)容不同，所以模板也有別。可用通用的EPR模型 用表格表示:固定、部分可變、完全動(dòng)態(tài)四、EPR的數(shù)據(jù)錄入（1）自然語(yǔ)言處理文本數(shù)據(jù)：自然語(yǔ)言的自由文本輸入。通過自然語(yǔ)言編輯器（WORD.XML等）自由錄入。也可通過自然語(yǔ)言識(shí)別系統(tǒng)（如OCR、語(yǔ)音識(shí)別）輸入。（2）結(jié)構(gòu)化文本輸入在規(guī)范結(jié)構(gòu)化模板的前提下，提供術(shù)語(yǔ)系統(tǒng)和良好的用戶界面，通過人機(jī)交互輸入。結(jié)構(gòu)化模板可以是靜態(tài)不便的，也可以是動(dòng)態(tài)可變的。非文本數(shù)據(jù):由檢查、檢驗(yàn)生成的影像、信號(hào)都是非文本數(shù)據(jù)。在HIS尚不完善的醫(yī)療機(jī)構(gòu)中電子化病歷要輸入這類數(shù)據(jù)十分困難。醫(yī)生只能憑借間接報(bào)告作為決策支持。在完善的HIS情況下，醫(yī)生可方便地獲取這類影像和信號(hào)的原始數(shù)據(jù)及報(bào)告，為診斷決策提供有力支持。五、電子病歷中的時(shí)間表達(dá)病歷中標(biāo)記時(shí)間的重要性:病人病程隨時(shí)間演變、醫(yī)生對(duì)疾病的變化隨時(shí)間而加深、治療方案中的行為都有特定的時(shí)間間隔。病歷必須對(duì)事實(shí)做如實(shí)反映，過后修改病歷是非法的。應(yīng)通過時(shí)間表達(dá)事實(shí)經(jīng)過與觀點(diǎn)的逐步形成過程。醫(yī)療行為必須在恰當(dāng)?shù)那昂蟊尘爸薪忉?。如醫(yī)生采取某一行為，某些現(xiàn)象當(dāng)時(shí)未發(fā)生，過后才發(fā)生。這種情況下，醫(yī)生對(duì)事后看來是不正確的行為是沒有責(zé)任的。時(shí)間表達(dá)的方法:絕對(duì)時(shí)間或相對(duì)時(shí)間。（并非絕對(duì)時(shí)間一定優(yōu)于相對(duì)時(shí)間，相對(duì)時(shí)間明了時(shí)間間隔。）注意:病歷中時(shí)間與其他事件表達(dá)的規(guī)范性。如應(yīng)記錄，什么時(shí)間由誰(shuí)觀察、什么時(shí)間由誰(shuí)錄入、什么時(shí)間開始應(yīng)用或執(zhí)行等。六、電子病歷的目標(biāo)電子病歷標(biāo)準(zhǔn)化的關(guān)鍵在于實(shí)現(xiàn)臨床信息系統(tǒng)在醫(yī)療保健組織內(nèi)部和醫(yī)療保健組織之間高水平的互操作（interoperability）。最終目標(biāo):全球范圍內(nèi)的互操作初始的目標(biāo):單個(gè)地區(qū)或國(guó)家內(nèi)的互操作任何一個(gè)電子病歷產(chǎn)品或系統(tǒng)的標(biāo)準(zhǔn)化的主要好處在于:互操作安全/保密質(zhì)量/可靠性效率/有效性七、電子病歷的范圍涉及電子病歷的所有組成元素,如結(jié)構(gòu),術(shù)語(yǔ),消息發(fā)送,安全,隱私等。此外,還包括智能決策支持功能（語(yǔ)法的）上的互操作性,以及豐富的知識(shí)水平（語(yǔ)義的）上的互操作性。圖1

電子病歷標(biāo)準(zhǔn)的范圍電子病歷本身的特征和范圍，也明確決定了電子病歷的標(biāo)準(zhǔn)需求的范圍:通常包含單一個(gè)體的診療信息，初步目標(biāo)是支持現(xiàn)在的或是將來該個(gè)體的醫(yī)療活動(dòng)，主要提供臨床信息。例如:出院轉(zhuǎn)診保健計(jì)劃臨床表現(xiàn)病史摘要急診數(shù)據(jù)集電子化的用藥記錄不良反應(yīng)報(bào)告電子處方在藥物試驗(yàn)中個(gè)人的健康信息的安全保密八.

電子病歷標(biāo)準(zhǔn)的建模視角表1.電子病歷標(biāo)準(zhǔn)的建模視角舉例應(yīng)用視角系統(tǒng)視角業(yè)務(wù)視角主要的EHR框架或模型在EHR環(huán)境中網(wǎng)絡(luò)及應(yīng)用系統(tǒng)觀點(diǎn)的基礎(chǔ)上基于醫(yī)療保健的功能及過程基礎(chǔ)上的EHR觀點(diǎn)應(yīng)用框架或模型幫助將標(biāo)準(zhǔn)分類例如:兩水平建模，提出下面標(biāo)準(zhǔn)：框架（參考模型）臨床概念模型RM-ODP,標(biāo)準(zhǔn)類型:例如:ISO的衛(wèi)生信息框架標(biāo)準(zhǔn)，可描述為：.抽象水平主題衛(wèi)生信息基礎(chǔ)構(gòu)成框架，標(biāo)準(zhǔn)有：表3.不同層次各類型標(biāo)準(zhǔn)的描述和舉例9.

電子病歷的組成和結(jié)構(gòu)圖2電子病歷的構(gòu)成在電子病歷參考結(jié)構(gòu)中，有8部分必需的框架結(jié)構(gòu)，它們分別為:1.結(jié)構(gòu)1.1記錄組織1.21.3數(shù)據(jù)組織數(shù)據(jù)類型及形式1.4健康概念的表示法2.過程2.1臨床過程2.2

記錄過程3通信3.1消息3.2記錄交換隱私與安全隱私與機(jī)密性知情同意進(jìn)入控制數(shù)據(jù)完整性非否定性（通信術(shù)語(yǔ)）訪問核查能力醫(yī)師及其行為的合法性法律支持參與者臨床或管理能力誠(chéng)實(shí)相關(guān)醫(yī)療活動(dòng)的表述記錄的永久性版本控制倫理對(duì)倫理問題的支持消費(fèi)者/文化消費(fèi)者問題文化問題發(fā)展對(duì)EHR結(jié)構(gòu)及EHR系統(tǒng)發(fā)展的支持電子病歷的其它結(jié)構(gòu)性標(biāo)準(zhǔn)文檔結(jié)構(gòu)文檔的元數(shù)據(jù)分類應(yīng)用程序框架技術(shù)框架專門的最小數(shù)據(jù)集以及疾病登記,比如急診醫(yī)學(xué),糖尿病,腫瘤,法定的可以更改的疾病。我國(guó)目前的發(fā)展階段HRS-CIS交互界面(1)醫(yī)院層次的研究探索(2)依賴CIS系統(tǒng)的完善(3)沒有建立能夠管理各醫(yī)療機(jī)構(gòu)EPR,進(jìn)行互操作的HRS系統(tǒng)(4)關(guān)于EPR院外應(yīng)用,尚缺乏一系列標(biāo)準(zhǔn),如關(guān)于EPR內(nèi)容的數(shù)據(jù)元素標(biāo)準(zhǔn)、數(shù)據(jù)集標(biāo)準(zhǔn)（出院、轉(zhuǎn)診、診療計(jì)劃摘要、特定疾病等）。（5）EPR院外應(yīng)用,應(yīng)依賴報(bào)告、消息發(fā)送或制定元數(shù)據(jù)標(biāo)準(zhǔn)。電子病歷開發(fā)案例研究方法按照面向?qū)ο蟮乃枷?將電子病歷分為分析、設(shè)計(jì)和實(shí)現(xiàn)三個(gè)階段。HL7給