医院信息化中医疗数据平台的现实应用探讨

目的:了解本地区医院信息化中医疗数据平台的现实应用情况,为推动信息化建设提供参考。方法:以30家我市卫生系统二级以上公立医院(三级医院6家,二级医院24家)为调查对象,调查表内容包括四个部分,包括医院基本情况、信息化部门设置规划情况、资金投入情况和医院数据平台应用情况。结果:有18家医院有信息化发展规划,4家医院信息化发展无规划。医院信息建设资金主要投入方向在硬件,其中二级医院的硬件投入大大超过软件投入,差异有显著性(P<0.05)。同时医疗数据使用平台的效率也不一样,住院病人出入管理系统,门急诊划价收费系统,门急诊药房管理系统使用率排在前三位,使用率最低的为门急诊导医系统。结论:本市医院医疗数据平台的建设大多数还停留在第一个阶段,也是一项复杂的系统工程,要加强信息化工作的组织领导和制定相应的信息化标准规范,建立信息主管制,加大信息化建设的资金投入,真正做到为患者服务。     

电子病历系统在医院信息管理系统中应用初探

电子病历系统是通过计算机等电子设备为载体,对医院患者的诊疗活动进行数字化记录的软件。电子病历中详细记录了医嘱、病程、过敏史、影像检查结果、出院记录等多项医疗数据。电子病历完整、系统、科学地记录了患者身体健康情况以及历次就诊记录,通过一个维度将患者内部不同层次的信息有机的联系在一起。与传统的纸张病历相比,电子病历可以迅速实现不同时间、不同医院医疗信息的高效整合以及信息共享,为临床诊疗提供大量科学准确的信息,大大提高医院的服务效率。本文通过电子病历系统在医院信息管理系统中的应用情况进行简要分析,以期提高电子病历系统在临床中解决实际医疗问题的能力。     

Medicaid and the Mainstream: Reassessment in the Context of the Taxpayer Revolt

California''s Medicaid program—Medi-Cal—attempted to implement the ideal of mainstream medical care for the poor by giving program beneficiaries a “credit card” for use in the private health care marketplace. This exposed the program to the perverse economic incentives of the fee-for-service, costplus health care system, and contributed to a high rate of increase in program costs. Attempts to control costs have been equally perverse, resulting in low payment rates, the second-guessing of physician professional judgments, the probing of medical and fiscal records, and the use of computerized surveillance systems.Attempts to shift to the use of more efficient delivery systems have had small success. Attempts to attain cost containment through restructuring the Medi-Cal program have been rejected in the name of the mainstream ideal. Costs have continued to escalate, with annual increases as high as 20 percent in some years. Medi-Cal now costs $4 billion per year, the largest single program in California state government.The taxpayer revolt in California is creating a fiscal crisis that will force rethinking of the premises of publicly funded health care for the poor, and a restructuring of strategies for reaching that objective. In the short run, it appears that the issue may not be whether the indigent will have access to mainstream medical care, but whether they will have access to any medical care. In the longer run, the crisis should represent an opportunity for building a system of health care that can serve the financially disadvantaged at a cost tolerable to our society.     

IMPAX PACS在黑龙江省区域化医疗远程会诊中的初步应用

目的:研究黑龙江省不同医疗机构之间新型协同服务模式,加强垦区各级医疗机构的信息化基础建设,建立基于医学影像存档与通信传输系统(Picture Archiving and Communications System,PACS)的数字化医疗区域。方法:将哈尔滨医科大学附属第四医院现有的影像数据归档,集成到IMPAX PACS数据中心(Internet Data Center,IDC),作为整个区域医疗的影像中心。通过IDC交换平台的延伸覆盖,以及医院信息系统(Hospital Information System,HIS)与XERO集成,可经网络调阅IDC中的影像,实现远程影像会诊。结果:建立基于IMPAX PACS的区域医疗;工程覆盖1家省会大医院和垦区2家综合性医院、5家二级医院、11家农场医院,实现联网医院间的影像学远程会诊。结论:PACS区域远程医疗系统的建立为基层百姓就医提供方便,影像学远程会诊可有效避免影像学重复检查,双向转诊、信息共享给患者带来更多的便利和实惠,具有巨大的社会效益。     

DISASTER CARE FOR 15 MILLION CALIFORNIANS

The urgency of the crisis following a nuclear attack staggers the imagination. We would have thousands or millions of survivors making a desperate struggle to survive. Safe water supplies and waste-disposal systems would be gone. In some areas, there would be little or no food or shelter.Yet California has already manned a medical arsenal that is second to none in the United States. We have stored 115 emergency hospitals at strategic points, and through the county medical associations we have appointed cadres including physicians, nurses and technicians. Plans have been made for workers who will assist in setting up the hospitals and first aid stations.In our future operations we will continue to place strong emphasis on the medical phase of our program of disaster care.The program would be just as essential in the event of major natural disaster as nuclear war.Our objective is a simple one. We are seeking to preserve the human resources which are necessary for recovery.California''s medical profession, with the allied professions of nursing and technical skills, has a vital interest in continuing operations to the maximum extent even under the most trying conditions.     

Doctors' use of electronic medical records systems in hospitals: cross sectional survey

ObjectivesTo compare the use of three electronic medical records systems by doctors in Norwegian hospitals for general clinical tasks.DesignCross sectional questionnaire survey. Semistructured telephone interviews with key staff in information technology in each hospital for details of local implementation of the systems.Setting32 hospital units in 19 Norwegian hospitals with electronic medical records systems.Participants227 (72%) of 314 hospital doctors responded, equally distributed between the three electronic medical records systems.ResultsMost tasks listed in the questionnaire (15/23) were generally covered with implemented functions in the electronic medical records systems. However, the systems were used for only 2-7 of the tasks, mainly associated with reading patient data. Respondents showed significant differences in frequency of use of the different systems for four tasks for which the systems offered equivalent functionality. The respondents scored highly in computer literacy (72.2/100), and computer use showed no correlation with respondents'' age, sex, or work position. User satisfaction scores were generally positive (67.2/100), with some difference between the systems.ConclusionsDoctors used electronic medical records systems for far fewer tasks than the systems supported.

What is already known on this topic

Electronic information systems in health care have not undergone systematic evaluation, and few comparisons between electronic medical records systems have been madeGiven the information intensive nature of clinical work, electronic medical records systems should be of help to doctors for most clinical tasks

What this study adds

Doctors in Norwegian hospitals reported a low level of use of all electronic medical records systemsThe systems were mainly used for reading patient data, and doctors used the systems for less than half of the tasks for which the systems were functionalAnalyses of actual use of electronic medical records provide more information than user satisfaction or functionality of such records systems     

Electronic health records: the European scene.

Caring for patients'' health problems relies increasingly on sharing information between clinical departments and disciplines and with managers. The medical record of the future will need to provide a flexible and shareable framework for recording and analysing the consultation process. The advanced informatics in medicine (AIM) programme seeks to encourage research and development in telemedicine in areas that are beyond the scope of any one country. It includes many European projects attempting to define the best storage and transmission formats for such diverse data types as laboratory results, biosignals, x ray images, and photographs, and in clinical specialties varying from intensive care to medicine for elderly people. One example, the good European health record project, is developing a model architecture for computerised health records across Europe that is capable of operating on a wide variety of computer hardwares and will also be able to communicate with many different information systems. The ultimate European health record will be comprehensive and medicolegally acceptable across clinical domains, hold all data types, and be automatically translated between languages.     

PREPARATION FOR DISASTER IN CALIFORNIA

The operational plan for medical preparedness in California is divided into three main divisions, viz: Expansion of existing medical facilities, augmentation of practicing health personnel, scope of service expected.Medical and health personnel and facilities will be expected to modify and adjust their care of casualties according to the situation present such as strategic warning, alert signal (yellow), take cover signal (red), and the post-attack period.This service is concerned with conservation of resources (human) and must do everything possible to return people to a status where they can help rebuild our nation.Supplies already obtained and stored throughout the state consist of first aid stations, emergency hospitals, blood procurement equipment, sanitation units.Over a half million first aiders and more than 96,000 home nurses have been trained by the local chapters of the American National Red Cross.     

Smart cards--the key to trustworthy health information systems.

Some 20 years after they were first developed, "smart cards" are set to play a crucial part in healthcare systems. Last year about a billion were supplied, mainly for use in the financial sector, but their special features make them of particular strategic importance for the health sector, where they offer a ready made solution to some key problems of security and confidentiality. This article outlines what smart cards are and why they are so important in managing health information. I discuss some of the unique features of smart cards that are of special importance in the development of secure and trustworthy health information systems. Smart cards would enable individuals'' identities to be authenticated and communications to be secured and would provide the mechanisms for implementing strong security, differential access to data, and definitive audit trails. Patient cards can also with complete security carry personal details, data on current health problems and medications, emergency care data, and pointers to where medical records for the patient can be found. Provider cards can in addition carry authorisations and information on computer set up.     

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou,China

Objectives

China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China.

Methods

The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores.

Results

After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001).

Conclusions

This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care.     

医疗质量与安全信息化监管系统架构研究

随着医疗信息技术的发展和使用,运用信息化手段开展医疗质量与安全精准化监管正在被越来越多的医院管理者所重视和接受。文章从组织保障体系建设、总体框架设计、基础数据库的标准化、主要监管内容筛选及电子病历系统等方面对医疗质量与安全信息化监管系统总体建设机构进行研究和讨论,期望能够指导医院充分利用和发挥医疗信息技术的优势,建立医疗质量与安全信息化监管系统,为制定质量管理持续改进的目标与评价改进的效果提供依据。     

POLESAT,an innovative e-health geomatic platform in decision-making based on: Geographical approach,medical knowledge visualization and geographic information system & web-mapping architecture

Our goals today, through the updated POLESAT project (version 2), are to improve the usability of the e-health geomatic platform with the help of a geo-medical e-Atlas and an innovative and modern methodology: a graphic language called “medical knowledge visualization”, dynamic and interactive web pages orchestrated by relational management database system, web and map servers.ResultsThis new prototype offers an example of three geo-referenced public hospitals (Dunkerque, Lille and Valenciennes) and its medical information system statistics and associated mapping. The Nord–Pas-de-Calais e-Atlas is displayed and accessible by users thanks to an advanced and secured web-mapping technology.Discussion and conclusionThanks to geographical access with the map, a medical graphic language (by clicking on PiNoKio's anatomy linked to hospital activity) and modern geographic information system architecture, we responded to the first critical assessments. The next version of e-Atlas will evolve into a whole open source environment and will be the subject of a future campaign whose goal will be a programmed medical choice.     

THE CALIFORNIA TUMOR REGISTRY—A Summary Report on the Cancer Experience in 36 Hospitals

The California Tumor Registry was started in 1947. It consists of case abstracts of medical records on neoplasm patients seen in 40 hospitals in California and now contains data on more than 159,000 cases, with 15,000 new cases being added each year. Follow-up reports are requested annually on each case not known to be dead.The Registry is designed to (1) promote the continuing care of the patient, (2) to evaluate cancer control methods, (3) to advance knowledge of the epidemiology of cancer, and (4) to suggest leads for laboratory and clinical research.From a series of 110,628 neoplasm cases reported to the California Tumor Registry in 1942-1954, data are presented on 76,499 cancer cases initially diagnosed in reporting hospitals. Histopathologic confirmation, age, sex, stage, treatment, follow-up, and survival of cancer patients are discussed. Use of the Registry information for analyzing cancer experience for epidemiological study and for evaluation of treatment methods are also described.The report is intended to illustrate the types of data that can be obtained from the California Tumor Registry. More comprehensive reports on specific aspects of cancer control will be forthcoming.     

The California Tumor Registry: a summary report on the cancer experience in 36 hospitals

The California Tumor Registry was started in 1947. It consists of case abstracts of medical records on neoplasm patients seen in 40 hospitals in California and now contains data on more than 159,000 cases, with 15,000 new cases being added each year. Follow-up reports are requested annually on each case not known to be dead. The Registry is designed to (1) promote the continuing care of the patient, (2) to evaluate cancer control methods, (3) to advance knowledge of the epidemiology of cancer, and (4) to suggest leads for laboratory and clinical research. From a series of 110,628 neoplasm cases reported to the California Tumor Registry in 1942-1954, data are presented on 76,499 cancer cases initially diagnosed in reporting hospitals. Histopathologic confirmation, age, sex, stage, treatment, follow-up, and survival of cancer patients are discussed. Use of the Registry information for analyzing cancer experience for epidemiological study and for evaluation of treatment methods are also described. The report is intended to illustrate the types of data that can be obtained from the California Tumor Registry. More comprehensive reports on specific aspects of cancer control will be forthcoming.     

公立医疗机构政府补偿与监管机制的研究框架

在补偿机制扭曲、政府监管滞后的背景下,科学设定公立医疗机构政府补偿标准和方式,改进政府监管手段和能力对保障公立医疗机构公益性具有重要意义。上海市闵行区开展了基于公益性绩效的政府补偿机制改革和基于信息平台的政府监管机制改革。文章以新公共行政理论为指导,总结闵行区政府补偿和监管机制的特点,评价改革的效果,并且探索分析补偿和监管机制改革对医疗机构运行绩效的影响,为深化公立医院改革提供决策参考。     

A Qualitative Exploration of Workarounds Related to the Implementation of National Electronic Health Records in Early Adopter Mental Health Hospitals

Aims

To investigate the perceptions and reported practices of mental health hospital staff using national hospital electronic health records (EHRs) in order to inform future implementations, particularly in acute mental health settings.

Methods

Thematic analysis of interviews with a wide range of clinical, information technology (IT), managerial and other staff at two early adopter mental health National Health Service (NHS) hospitals in London, UK, implementing national EHRs.

Results

We analysed 33 interviews. We first sought out examples of workarounds, such as delayed data entry, entering data in wrong places and individuals using the EHR while logged in as a colleague, then identified possible reasons for the reported workarounds. Our analysis identified four main categories of factors contributing to workarounds (i.e., operational, cultural, organisational and technical). Operational factors included poor system integration with existing workflows and the system not meeting users'' perceived needs. Cultural factors involved users'' competence with IT and resistance to change. Organisational factors referred to insufficient organisational resources and training, while technical factors included inadequate local technical infrastructure. Many of these factors, such as integrating the EHR system with day-to-day operational processes, staff training and adequate local IT infrastructure, were likely to apply to system implementations in various settings, but we also identified factors that related particularly to implementing EHRs in mental health hospitals, for example: EHR system incompatibility with IT systems used by mental health–related sectors, notably social services; the EHR system lacking specific, mental health functionalities and options; and clinicians feeling unable to use computers while attending to distressed psychiatric patients.

Conclusions

A better conceptual model of reasons for workarounds should help with designing, and supporting the implementation and adoption of, EHRs for use in hospital mental health settings.     

THE SCOPE AND RESPONSIBILITY OF MEDICINE: A Forum with a Purpose

Many physicians and others are convinced that there is a pressing need for more discussion and more agreement concerning what ought to be the scope of medicine in today''s society. At the present moment, there is no general consensus either within or without the profession. Yet if the responsibility is ever to be met, its scope must be recognized and somehow defined.The editors of California Medicine propose to provide a forum in this journal for discussion of the scope and responsibility of medicine. This is a forum with a purpose, and so far as is known, an innovation in medical journalism. The forum is initiated with the statements beginning on the following page. Readers and others are invited to submit their views constructively and succinctly. As many of these as space permits will be published in future issues of California Medicine as a continuation of this forum. At an appropriate time all the material will be collated and, if feasible, the distillate will be prepared in the form of a statement on “The Scope and Responsibility of Medicine” to be submitted to the Council of the California Medical Association for its consideration.The statements which follow are the concisely expressed views of distinguished scholars, educators, statesmen and practitioners in the health field. It is hoped their views on this timely and important subject will provoke thought and comment among the readers of this journal     

Voluntary Health Insurance Coverage in California, 1961: A Report of the Bureau of Research and Planning, California Medical Association

Almost 7 out of every 10 of the estimated population of 16.2 million persons in California, were covered under some form of voluntary health insurance at the end of 1961. The forms of protection included hospital, surgical, regular medical and major medical expense benefits. The per cent of the civilian population of California covered for surgical benefits was slightly over 66 per cent, while 56 per cent were covered for regular medical expense benefits. Comparable percentages for the United States are approximately 74 per cent (hospital), 69 per cent (surgical), and 51 per cent (regular medical). While the percentage of the State's population covered for hospital and surgical expenses is below that for the United States, it is higher for regular medical expense benefits. The rate of increase in coverage for the different forms of health care protection in California exceeded the rate of population growth during the one-year period ending 1961. The foregoing summary and the information in the accompanying text, does not reflect the total number of persons in California who receive or are eligible for health care services. A large variety of government financed programs on local, state and federal levels either finance or provide such services to an estimated 40 to 50 per cent of the California population, which does not have voluntary health insurance coverage. No current data are available regarding the number of persons who do not desire voluntary health insurance coverage for a variety of personal or financial reasons.     

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.     

Medical and Health Care in State Residential Institutions for Children and Youths: A Report of Survey Findings in Five Hospitals

A survey of five Northern California state residential institutions showed considerable variation in the type and amount of medical services provided for children and youths. There was no standard policy for relationships with regional centers, use of community hospitals, vision and hearing assessments, speech and rehabilitation therapy, or genetic and maternal health services. Some hospitals had no staff members certified to carry out cardiopulmonary resuscitation (CPR). Not all staff physicians and other health professionals working in state hospitals had specific training in the areas of genetics, seizure control and physical rehabilitation medicine. While all five state hospitals are involved in training personnel, there is a need to develop a statewide plan for the better sharing of knowledge and expertise of the state hospital personnel in the training of pediatricians and others.