眼眶病科电子病历系统的建立和应用

目的设计与开发眼眶病科电子病历，以实现对眼眶病科病人信息的采集、加工、存储和传输。方法以Microsoft SQL Server2005为后台数据库、Microsoft Visual Studio2005为前台开发工具，通过建立一个以医学图像存储为主的结构化病历，实现了眼眶病科电子病历系统。结果该病历系统已在眼眶病科使用，实践证明，其运行稳定、查询快捷、操作简明、信息显示丰富、打印详尽。结论该系统能够有效提高医生的工作效率及医疗质量，为眼眶病科病例数据的收集及将来全面实现电子病历积累了宝贵经验。     

手外科电子病历的设计与实现

目的 设计开发手外科电子病历系统.方法 以SQL Server 2005为后台数据库、以Delphi 7.0为前台开发工具,建立结构化手外科电子病历.结果 系统运行良好,实现了用计算机技术管理手外科病人医疗信息.结论 该系统能有效提高医生书写病历的效率与质量,减轻医生的工作量,为将来全面实现电子病历打下基础.     

基于卫生信息平台的电子病历信息共享研究和实现

研究信息共享的关键技术,通过电子病历的标准化和结构化处理、传输和交换,实现电子病历信息的共享。在卫生部电子病历数据标准的基础上,结合采用情景分析法和层次分析法,通过Delphi法专家咨询确定电子病历可以结构化的数据项,实现电子病历的标准化和结构化处理;然后运用SWOT分析法,结合应用可扩展标记语言（XML）和临床文档结构标准（CDA）两项技术,实现电子病历的标准化传输和交换,使得电子病历信息在传输和交换过程中能够被机器自动识别,实现数据的自动化传输和交换;最后,研发电子病历完整性测试系统,实现电子病历完整性的自动测试。完成电子病历信息标准化和结构化处理、传输和交换全流程的技术研究,形成技术规范。有123家医院实现电子病历标准化上传省级卫生信息平台,有16家电子病历提供商具备了电子病历标准化和结构化处理、传输和交换能力。初步实现了电子病历的信息共享,电子病历数据传输技术规范作为浙江省地方标准正式颁布实施。     

电子病历一卡通系统的研发与应用

目的 研发电子病历一卡通系统,用于优化就医流程,提高工作效率和医院现代管理水平.方法 利用查询策略和数据归档方法,从操作系统、数据库管理系统、应用系统3个层面设计了比较完整的安全方案和实现方法.运用Powerbuild等工具开发电子病历一卡通系统实例.结果 该实验系统测试运行正常,实现病人病历数据化.通过IC卡,实现病人一个ID号对应一个IC卡,并能一卡多用.实现病人医疗保健档案和终生的个人信息的存储、管理和使用.缩短病人看病时间.结论 该系统方便了病人就医,提高了医生工作的准确度和效率,提高了医院的管理水平和监督力度.     

一体化数字医院的医生工作站与电子病历

本文结合作者单位推行一体化医生工作站的实践，阐述了医生工作站与电子病历、临床信息系统与电子病历的关系，较详细介绍了系统的结构和功能、医嘱处理和电子病历编辑器的特点，概括了支持电子病历的采集、存储，处理、传递、保密和表现（利用）等整个生命周期的完整解决方案，最后对电子病历使用中的一些体验进行了讨论。     

医院信息系统中门诊电子病历的设计与研究

基于医院信息系统的设计与开发,对门诊电子病历进行了设计、研究与实现,并在此基础上分析了临床诊疗、医院管理工作对电子病历的要求,研究了电子医嘱模板的形式对临床诊疗的满足情况,与目前比较普遍采用的电子病历的设计方法作了对比。系统采用MSSQL2000数据库存储与电子病历相关的信息。利用PowerBuilder9.0编写代码与制作界面,实现整个系统的功能。     

基于电子病历的医院信息平台的关键技术

目的：医院信息平台包括管理信息系统和临床信息系统,电子病历系统处于整个系统的中心位置,要以电子病历为核心构建基于电子病历的医院信息平台。方法：1、构建以电子病历为核心的体系架构,该体系框架由门户、应用、服务、资源、交换、业务、基础设施、标准、安全体系和运维管理共九层组成。2、建立临床数据存储库CDR,CDR数据来源于医院信息平台的临床和管理信息系统,按规定格式进行存储和归档后,供信息系统用户调用。3、实现信息系统集成,SOA模式是面向服务架构的新型集成体系,通过企业服务总线（ESB）实现,它将软件的功能设计成一个个独立封装的服务,并通过信息交换协议进行发布,达到无界限的联通和软件复用。结果：基于电子病历的医院信息平台满足医院信息系统应用和基础设施整合的需求。CDR支持及时性的、操作性的、集成性的整体临床信息的应用,实现面向主题的、集成的、标准的、可变的、当前的细节数据集合。SOA模式可以通过企业服务总线（ESB）实现,ESB将集线器模式的星形结构扩展为总线结构,将总线上的各个服务按照用户需要的业务逻辑组装起来,使这些服务按照业务逻辑顺序执行,从而实现用户完整的业务功能。结论：基于电子病历的医院信息平台结构、CDR数据存储结构和采用ESB技术的SOA集成模式是构建新一代医院信息系统的关键技术。     

电子病历与"军字1号"医生工作站

随着计算机及信息技术发展，传统的HIS系统逐步向以病人信息为重点的综合信息管理体系发展，“军字1号”系统实现了由传统的HIS向电子病历系统的过渡，本文就电子病历发展及“军字1号”医生工作站的使用作简要的介绍，指出如何简化各类申请单的操作，添加处方生成，查阅各种信息等，并对病历的结构。内容、显示方式及导出等进行探讨。     

基于SQL SERVER2008的眼科电子病历系统的研制

目的：电子病历系统在现代医学信息处理中占有很高的地位,本文针对医院对于眼科病人信息管理的实际需求,开发了一个眼科电子病历系统,以实现对患者的诊疗信息的管理及眼底图像的处理。方法：系统采用SQL SERVER2008作为应用数据库,ActiveX数据对象（Active Data Object简称ADO）的方式连接数据库,以Visual Studioc＋＋6．0作为开发语言,采用SQL语句拼接的方法实现高级查询,采用改进的Back Propagation（BP）神经网络算法进行图像的分割及处理。结果：该眼科电子病历系统包括系统管理、病人信息管理、信息查询及图像管理等四个模块,可实现患者信息的管理、高级查询及统计分析等功能,另外,还可对眼科眼底造影图像进行处理,可手动及自动测量眼底血管管径及不规则病变的面积。结论：通过SQL语句拼接实现对数据库的高级检索,极大地提高了数据库的操作效率。系统给出的眼底血管和病变面积的测量数据,可为眼底病变的诊断、治疗及预后评估等提供依据。总之,该眼科电子病历系统提供了一个操作简便．界面友好的工具,有助于临床诊疗、教学及科研工作。     

一种符合医学数字影像与通讯标准的医学影像管理系统的设计

医学影像的存储与传输在数字化医疗快速发展的今天占据着非常重要的地位。为了实现医学数字影像与通讯（DICOM）医学影像在局域网上的传输和查询,本文设计了一个符合DICOM标准的医学影像管理系统。该系统能对DICOM格式文件进行解析,并在数据库中把DICOM影像文件与对应的病历信息进行关联存储,可以给医院影像科提供完全数字化的影像和数据。此研究工作不仅满足了医院影像中心对大量影像数据存储的需求,同时也促进了PACS系统的发展。     

Use of and attitudes to a hospital information system by medical secretaries,nurses and physicians deprived of the paper-based medical record: a case report

Background  

Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS). This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians.     

Summary of an electronic chart system in Anjo Kosei hospital and clinical laboratory system

Many companies are introducing PC systems, and management administration can be done more effectively. Management administration was previously paper-based was, but, with improved PC information systems, their adoption is inevitable. This is the situation facing the Mayor of Ministry of Health and Welfare Health Policy Bureau, the medical and pharmaceutical safety chief of the bureau, the guidelines about "saving medical examination and treatment records on electronic media" by the insurance chief of the bureau joint signature notification on April 22, 1999, the spread of the electronic chart system which changes a patient's paper record, aiming at patient's record disclosure, standardization of data, and equalization of medical quality to no longer be an exception in medical care. At this symposium, I presented a summary of the electronic chart system and the inspection system that this House introduced concentrating on the particularly special functions.     

放射治疗中基于DICOM-RT模型的电子病历信息系统

电子病历(EMR)是医疗机构对门诊、住院患者(或保健对象)临床诊疗、指导干预的数字化医疗服务工作记录,是居民个人在医疗机构历次就诊过程中产生和被记录的完整、详细的临床信息资源。放射治疗EMR中包含文字、图像等信息,因此,比一般的EMR更加复杂。本文提出一种基于DICOM-RT标准的EMR信息系统,通过使用DICOM-RT的七个对象来实现放射治疗中不同系统、设备间的信息交换和共享,方便放射治疗患者治疗数据的管理,提高放射治疗的效率。     

The evolution of electronic medical records.

No clinical computing topic is being given more attention than that of electronic medical records. Health care organizations, finding that they do not have systems adequate for answering questions crucial to strategic planning and for remaining competitive with other provider groups, are looking to information technologies for help. Many institutions are developing integrated clinical workstations, which provide a single point of entry for access to patient-related, administrative, and research information. At the heart of the evolving clinical workstation lies the medical record in a new incarnation: electronic, accessible, confidential, secure, acceptable to clinicians and patients, and integrated with other, non-patient-specific information. The author describes the problems associated with paper-based record keeping and the promise of the electronic medical record, emphasizing the areas of clinical trials and decision support. He then discusses the issues that must be addressed and the requirements that must be met if electronic medical record systems are to move beyond intranet environments within single health systems or practices and to integrate with regional, national, and international resources via the Internet.     

No paper,but the same routines: a qualitative exploration of experiences in two Norwegian hospitals deprived of the paper based medical record

Background  

It has been shown that implementation of electronic medical records (EMR) and withdrawal of the paper-based medical record is feasible, but represents a drastic change in the information environment of hospital physicians. Previous investigations have revealed considerable inter-hospital variations in EMR system use and user satisfaction. The aim of this study was to further explore changes of clinicians' work after the EMR system implementation process and how they experienced working in a paper-deprived information environment.     

基于超声病历的数据库管理与分析系统

为了解决超声医学技术的快速发展带来的病历数激增而难以管理的问题,完成了超声病历数据库管理与分析系统的设计与验证。系统基于SQL Server数据库技术、Visual C#窗体应用程序技术、医学数据统计分析技术成功构建了一套以超声为核心的病历数据库管理与分析系统,同时系统留有电子病历、实验室检查、病理检查等数据接口,并将病历数据的常用统计分析算法结合起来。通过导入原有病历数据试验,超声科医生对于病历数据库的管理分析及相关课题研究效率提升50%以上。试验结果表明该系统有助于超声科医生对于病历数据的管理与分析,对提高医疗科研效率具有实际意义。     

Architectural design and tools to support the transparent access to hospital information systems,radiology information systems,and picture archiving and communication systems

The fragmentation of the electronic patient record among hospital information systems (HIS), radiology information systems (RIS), and picture archiving and communication systems (PACS) makes the viewing of the complete medical patient record inconvenient. The purpose of this report is to describe the system architecture, development tools, and implementation issues related to providing transparent access to HIS, RIS, and PACS information. A client-mediator-server architecture was implemented to facilitate the gathering and visualization of electronic medical records from these independent heterogeneous information systems. The architecture features intelligent data access agents, run-time determination of data access strategies, and an active patient cache. The development and management of the agents were facilitated by data integration CASE (computer-assisted software engineering) tools. HIS, RIS, and PACS data access and translation agents were successfully developed. All pathology, radiology, medical, laboratory, admissions, and radiology reports for a patient are available for review from a single integrated workstation interface. A data caching system provides fast access to active patient data. New network architectures are evolving that support the integration of heterogeneous software subsystems. Commercial tools are available to assist in the integration procedure.     

临床医师信息管理系统的开发

目的 开发适合医师个人使用的临床信息管理系统。方法 基于中文Windows XP系统，运用Access2002进行开发。结果 该系统集成了电子病历管理系统（CPR）和医学影像信息系统（PACS）的相关功能，以及医学文档处理系统（Medicine Ofice）、电子图书馆及多条件查询系统，可快捷建立、编辑、存储和查询文本、图像、语音、影像和统计等不同格式的临床资料，并可访问因特网。结论 该系统功能强大，性能稳定，有助于提高临床医师的工作质量与效率，具有广阔的应用前景。     

Patients' experiences when accessing their on-line electronic patient records in primary care.

BACKGROUND: Patient access to on-line primary care electronic patient records is being developed nationally. Knowledge of what happens when patients access their electronic records is poor. AIM: To enable 100 patients to access their electronic records for the first time to elicit patients' views and to understand their requirements. DESIGN OF STUDY: In-depth interviews using semi-structured questionnaires as patients accessed their electronic records, plus a series of focus groups. SETTING: Secure facilities for patients to view their primary care records privately. METHOD: One hundred patients from a randomised group viewed their on-line electronic records for the first time. The questionnaire and focus groups addressed patients' views on the following topics: ease of use; confidentiality and security; consent to access; accuracy; printing records; expectations regarding content; exploitation of electronic records; receiving new information and bad news. RESULTS: Most patients found the computer technology used acceptable. The majority found viewing their record useful and understood most of the content, although medical terms and abbreviations required explanation. Patients were concerned about security and confidentiality, including potential exploitation of records. They wanted the facility to give informed consent regarding access and use of data. Many found errors, although most were not medically significant. Many expected more detail and more information. Patients wanted to add personal information. CONCLUSION: Patients have strong views on what they find acceptable regarding access to electronic records. Working in partnership with patients to develop systems is essential to their success. Further work is required to address legal and ethical issues of electronic records and to evaluate their impact on patients, health professionals and service provision.