Electronic Medical Record (EMR) is a data integration system created, saved and used by medical institutions electronically, focusing on clinical diagnosis and treatment of outpatients, inpatients (or health care objects) and guiding intervention information; The complete and detailed clinical information resources generated and recorded in the medical institutions' previous visits; it is an information resource database that records the medical service activity records of medical diagnosis and treatment objects. The information resource database exists in a computer-processable form and can be stored safely. and transmission, which can be accessed by authorized users within the hospital.
2. Hospital Information System
Hospital Information System (HIS) refers to the use of computer software and hardware technology, network communication technology and other modern means to comprehensively manage the flow of people, logistics and financial flows of the hospital and its various departments; It is an information system that collects, stores, processes, extracts, transmits, summarizes, and processes the data to generate various information, thereby providing comprehensive, automated management and various services for the overall operation of the hospital.
3. Clinical Information System
The Clinical Information System (CIS) is an integral part of the hospital information system, which collects, stores, processes, extracts, transmits, summarizes and processes the data generated in each stage of medical activities to generate various information to support hospital medical care. The clinical activities of the personnel enrich and accumulate clinical medical knowledge; and provide clinical consultation, auxiliary diagnosis and treatment, and auxiliary clinical decision-making to improve medical quality and work efficiency.
It mainly includes a doctor's order processing system, a patient bedside system, a doctor's workstation system, a laboratory system, and a drug consultation system.
4. Laboratory System
The Laboratory Information System (LIS) is an integral part of the hospital information system, which mainly includes the functions of the laboratory information system and the clinical examination sub-system, blood bank, microbiological management, and clinical critical value management.
5. Medical Imaging System
The medical imaging system (Picture Archiving and Communication Systems, PACS) is a system applied in the imaging department of the hospital. images generated by equipment such as instruments, microscopes, etc.) are stored in a large number of digital ways through various interfaces; when needed, they can be quickly recalled for use under certain authorization, and some auxiliary diagnosis management functions are added; it is in the It plays an important role in transmitting data and organizing and storing data between various imaging devices.
2. Excavate the core issues of hospital informatization construction
1. Low data integration
Quite a few internal departments of hospitals have built independent radiology, ultrasound graphic reporting systems, pathological graphic reporting systems, and even laboratory information systems.
Many of these systems are established by departments according to their own business needs. These systems did not consider the integration with the hospital information system when they were established, or the hospital information system did not have the conditions for integrated application at that time, so they became isolated systems.
A common phenomenon is that with the development of hospital informatization, the data of these isolated systems cannot be integrated with the hospital information as a whole, or the change of manufacturers leads to these isolated systems having to be rebuilt; this not only leads to waste of funds, but also leads to the original system. The data saved in the system is difficult to inherit in the new system.
2. The construction of norms and standards is not well matched with the application of hospital information systems
In the process of hospital informatization construction in my country, few standards and specifications are adopted, and the sharing and exchange of information is mainly carried out in a "point-to-point" way. Serious consequences.
3. The sharing and utilization of information has not received attention
The main goal of hospital information work is the scope and quantity of data collected, but the sharing and in-depth use of these data after collection are often neglected.
For informatization work, the collection of information is basically an investment work, and the effective and timely use of information is the benefit of informatization work.
3. Data Governance - Top-level Design Scheme
1. Constructing the business field of hospital information platform
The division of business domains abandons the concept of the hospital's existing software system, and sorts out the hospital's business applications from the perspective of data exchange and sharing through the hospital information platform.
Through analysis, this plan divides the business fields (themes) of the hospital information platform based on electronic medical records into three first-level categories, namely: clinical services, hospital management (medical management, operation management), and platform applications.
Taking the clinical service domain as an example, the medical clinical business is divided into twelve domains, and each domain is subdivided into three-level categories to ensure that each three-level category has a business domain that country email list meets the national standards (Statistical Information Center of the Ministry of Health). identifier.
2. Classification of medical services and management personnel
3. Business activity modeling
Business modeling is based on the premise of sorting out and analyzing various business activities in the hospital, expounding the business flow mode based on the purpose of information exchange and sharing, showing the process of information exchange between various business activities through the hospital information platform, and developing an integrated platform, Internet for the hospital. Provide reference and guidance for the construction of the hospital.