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。     

电子病历管理模式下病案科组织结构设计思考

电子病历管理给医院管理带来了新的变革。加强医院电子病历管理,促进医院有效管理电子病历,保证电子病例的原始性是医院信息化建设的一项重要内容。针对并按科的组织结构模式进行分析,提出病案科的发展趋势,在相应组织结构设计原则的基础之上提出了强矩阵式电子病历管理结构。     

临床医师对电子病历相关知识认知的调查研究

目的:了解临床医师对电子病历书写的态度和行为现状以及电子病历管理和对医疗质量的认知等情况,为制定科学的电子病历管理方案提供借鉴。方法:选取两所2所三级甲等和2所三级乙等医院临床医师共计450名进行调查,采用问卷调查医师对电子病例相关知识(如临床医师对电子病例相关法规认知、电子病例监控对电子病历影响及电子病历优点等)的认知和需求。结果:临床医师电子病历总体书写现状调查显示,对于书写电子病历中相似的部分,48.7%(219例)的医师直接复制粘贴再修改;复制粘贴使用比率≥40%占76.7%(345例);电子病历书写出错原因主要为认为责任心不强(38.2%)和病历系统掌握不到位(29.6%);促进临床医师按要求写好病历的主要动力为法律证据(32.9%)和培养临床思维(49.1%);54.9%(247例)医师能对自己的病历进行经常检查;科室负责人对电子病历经常检查的占33.1%(149例);50%左右人员对电子病历系统操作掌握情况一般;79.33%的临床医师认为电子病历的使用有助于提高医疗质量;临床医师认为电子病历对医疗质量的影响主要是提高病历书写速率、病历完成及时性、管理系统性、病历安全性和患者满意度。结论:临床医师在电子病历书写中复制粘贴比例较高,且对相关的法律法规认识一般,对医院电子病历系统掌握不熟悉,应加大相关内容的培训,更有利于医院电子病历的管理。     

由传统病历向电子病历平稳过渡的探讨

随着现代化科学技术的飞跃发展,计算机及网络广泛地应用于社会各个领域,医院管理的信息化不断加强,传统病历已不能满足医学发展的需要。从传统病历向电子病历过渡是否顺利,将影响到很长一段时间内的医疗质量和医疗安全。结合北京天坛医院电子病历的使用情况,从电子病历使用者的角度探讨了如何实现由传统病历向电子病历的平稳过渡。     

云计算环境下电子病历一体化管理初探

在文件生命周期理论和文件连续体理论的基础上提出了电子病历一体化管理思想,分析电子病历一体化管理存在的障碍,阐述利用云计算技术进行电子病历一体化管理的必要性,从顶层设计、云服务模式选择、云平台构建、标准化建设、业务流程重组等方面加强电子病历一体化管理,使电子病历数据保持云端同步,从而提高电子病历的管理水平,方便数据提取和数据共享。     

电子病历疾病模板控制在病历质量管理中的作用

目的 探索通过对电子病历疾病模板的专业性和规范化的控制提高病历质量。方法 对某综合性三甲医院的临床医生进行问卷调查。内容包括：调查对象对电子病历相关管理规范的认识,疾病模板的合理性及数量,使用疾病模板对提高工作效率、科研水平及改善病历质量等方面的作用。结果 92.14%的人员认为使用电子病历模板后减少了病历书写时间,83.90%的人员认为使用模板后改善了病历书写质量,92.17%的人员认为使用模板对科研工作有利。另外仅有29.87%的调查对象了解电子病历模板的制作规范,了解程度较低。结论 完善的电子病历疾病模板对提高工作效率、科研水平及改善病历质量具有重要作用。但在实际应用过程中仍存在不足,亟待解决。完善病历模板、加强质量监控可以提高电子病历质量及信息利用率。     

基于电子病历的医疗质量控制与安全管理策略

电子病历是临床信息的集成平台,可以提供完整、安全、可交换、可挖掘的临床信息源,同时也可以改变传统的医疗质量监控与安全管理方式,提高质量和安全管理水平。介绍了基于电子病历的医疗质量控制与安全管理的一系列策略,主要包括数字化医疗质量监控管理平台、单病种临床路径管理系统、合理用药监测与处方点评系统、医疗过程控制与任务管理、危急值提醒与医疗安全警示、院内感染管理系统、重症病人监护管理系统、基于电子病历的无线移动技术和物联网技术的应用等。

     

电子病历个人信息保护法律规制

电子病历中储存的医疗数据属于患者的隐私，应当具有严格的保密性。在电子病历所有权界定不清的情况下，直接规定医疗机构是电子病历使用权的主体对医疗机构和患者均存在不利影响。我国目前缺乏对电子病历的法律规制，导致患者通过诉讼途径寻求法律救济的困难增大。从立法的层面进行思考，应当规范电子病历监管部门权责，加强对患者个人信息的法律保护，从而促进和谐医患关系的发展。     

皮肤病专科医院电子病历的设计与应用

???????目的 研究与开发具有皮肤病专科特色的电子病历系统,以实现皮肤科病人医疗信息的采集、加工、存储、传输和服务。方法 以windows sqlserver2005为后台数据库,以XML、C#为开发语言,建立皮肤病结构化病历。结果 该系统运行良好,安全稳定、易维护、通用性好。有效地提高了医生书写病历的速度和质量,并具有皮疹数码照片嵌入等功能。结论 本研究实现了具有皮肤病专科特色的电子病历系统,值得皮肤病医院推荐使用。     

浅谈电子病历应用中的患者知情权保护

患者知情权是患者的基本权利,目前医患信息的不对称凸显出患者知情权的重要性,电子病历作为医疗信息化产物被广泛应用,为患者实现知情权提供了捷径。但目前我国在电子病历应用中对患者知情权的保护尚有欠缺,主要体现在病历质量管理和病历公开两方面。因此,应推动相关法律法规的细化和落实,全面实现电子病历质控,并推进病历公开进程,改善患者知情权保护现状。     

Evaluation of Electronic Medical Record (EMR) at Large Urban Primary Care Sexual Health Centre

Objective

Despite substantial investment in Electronic Medical Record (EMR) systems there has been little research to evaluate them. Our aim was to evaluate changes in efficiency and quality of services after the introduction of a purpose built EMR system, and to assess its acceptability by the doctors, nurses and patients using it.

Methods

We compared a nine month period before and after the introduction of an EMR system in a large sexual health service, audited a sample of records in both periods and undertook anonymous surveys of both staff and patients.

Results

There were 9,752 doctor consultations (in 5,512 consulting hours) in the Paper Medical Record (PMR) period and 9,145 doctor consultations (in 5,176 consulting hours in the EMR period eligible for inclusion in the analysis. There were 5% more consultations per hour seen by doctors in the EMR period compared to the PMR period (rate ratio = 1.05; 95% confidence interval, 1.02, 1.08) after adjusting for type of consultation. The qualitative evaluation of 300 records for each period showed no difference in quality (P>0.17). A survey of clinicians demonstrated that doctors and nurses preferred the EMR system (P<0.01) and a patient survey in each period showed no difference in satisfaction of their care (97% for PMR, 95% for EMR, P = 0.61).

Conclusion

The introduction of an integrated EMR improved efficiency while maintaining the quality of the patient record. The EMR was popular with staff and was not associated with a decline in patient satisfaction in the clinical care provided.     

Neurobiological effects of microwave exposure: a review focused on morphological findings in experimental animals

The possible risk of electromagnetic radiation (EMR) for nervous system is regularly published from the middle of 20th century. Numbers of neurobiological studies demonstrate that various EMR frequencies induce changes in nervous tissue of experimental animals but the evidence for health effect of EMR to the nervous system remains uncertain. To solve the fundamental questions about possible health hazard of modern technologies, the main producers of EMR, further intensive experimental studies on animals are needed. This review, focused on morphological findings achieved in various experimental animals, demonstrates that blood-brain barrier is the most studied morpho-functional unit of CNS in experiments with EMR. The morphological findings in experimental animals, in many cases controversial, put some evidence on nervous tissue structural damage after the EMR exposure. In spite of numerous literary data a wide range of contemporary neuro-morphological methods waits to be utilized in the EMR experimental paradigm. Using these methods could play an important role in answering the question about possible adverse effects of microwaves on nervous system.     

Implementation of a Cloud-Based Electronic Medical Record to Reduce Gaps in the HIV Treatment Continuum in Rural Kenya

Background

Electronic medical record (EMR) systems are increasingly being adopted to support the delivery of health care in developing countries and their implementation can help to strengthen pathways of care and close gaps in the HIV treatment cascade by improving access to and use of data to inform clinical and public health decision-making.

Methods

This study implemented a novel cloud-based electronic medical record system in an HIV outpatient setting in Western Kenya and evaluated its impact on reducing gaps in the HIV treatment continuum including missing data and patient eligibility for ART. The impact of the system was assessed using a two-sample test of proportions pre- and post-implementation of EMR-based data verification and clinical decision support.

Results

Significant improvements in data quality and provision of clinical care were recorded through implementation of the EMR system, helping to ensure patients who are eligible for HIV treatment receive it early. A total of 2,169 and 764 patient records had missing data pre-implementation and post-implementation of EMR-based data verification and clinical decision support respectively. A total of 1,346 patients were eligible for ART, but not yet started on ART, pre-implementation compared to 270 patients pre-implementation.

Conclusion

EMR-based data verification and clinical decision support can reduce gaps in HIV care, including missing data and eligibility for ART. A cloud-based model of EMR implementation removes the need for local clinic infrastructure and has the potential to enhance data sharing at different levels of health care to inform clinical and public health decision-making. A number of issues, including data management and patient confidentiality, must be considered but significant improvements in data quality and provision of clinical care are recorded through implementation of this EMR model.     

Electromagnetic Radiation Influence on Nonlinear Charge and Energy Transport in Biosystems

The influence of electromagnetic radiation (EMR) on charge and energy transport processes in biological systems is studied in the light of the soliton model. It is shown that in the spectrum of biological effects of EMR there are two frequency resonances corresponding to qualitatively different frequency dependent effects of EMR on solitons. One of them is connected with the quasiresonance dynamic response of solitons to the EMR. At EMR frequencies close to the dynamic resonance frequency the solitons absorb energy from the field and generate intensive vibrational modes in the macromolecule. The second EMR resonance is connected with soliton decay due to the quantum mechanical transition of the system from the bound soliton state into the excited unbound states.     

Effects of extremely high-frequency electromagnetic radiation on the immune system and systemic regulation of homeostasis

Low-intensity of electromagnetic radiation of extremely high frequencies (EHF EMR) is effectively used in medical practice for diagnostics, prevention and treatment of a broad spectrum of diseases of different etiology. However, in spite of existence of many hypotheses about mechanisms of EHF EMR effects on the molecular and cellular levels of organization of living systems, there is not conception that could explain all diversity of the EHF-therapy effects from unified approach. In our opinion, the problem of determination of mechanisms of EHF EMR effects on living organism is divided into two basic tasks: first, determining subcellular structures which can receive radiation, and, second, studying physiological reactions of the organism which are caused by radiation. It is obviously, that investigation of functions of single cells and subcellular elements can not entirely explain therapeutic effects and mechanisms of EHF EMR influence on multicellular organism on the whole. Plenty of functional relationships between organs and systems of organs should be taken into account. In the present review, a realization of the EHF-therapy effects due to the influence on immune system functions and start of system mechanisms of maintenance of the homeostasis on the organism level is hypothesized. Potential targets for EHF EMR acception on the level of different systems of the organism are analysed. The material is formed so that functional relations between immune system and other regulatory systems (nervous and endocrine systems) are traced.     

Effect of low intensity electromagnetic radiation on the toxicity of domestic wastewater tested with the “Ecolum” test-system

Irradiation of wastewater by low intensity electromagnetic radiation (ν = 42.25 GHz) affects the integral toxicity of water of a different purification degree, which was revealed by an express method on the basis of the Ecolum-08 bacterial luminescent test system. We have shown that the lower the degree of water purification, the higher the toxicity effect of EMR. This allows us to propose the Ecolum bacterial luminescent test system for the primary testing of the effect of EMR.     

Functional Activity of the Sympathoadrenal System and Behavioral Indices of Rats: Changes Induced by Millimeter-Range Electromagnetic Radiation

We examined the ability of low-intensity millimeter-range (mmR) electromagnetic radiation (EMR) to modify the functional activity of the sympathoadrenal system (SAS) and the behavioral reactions in intact rats and rats with an experimentally induced stress reaction. Adaptation of the organism to mmR EMR has been shown to limit SAS activation; this is considered one of the mechanisms of the antistressor effect of such radiation.     

CD312, the human adhesion-GPCR EMR2, is differentially expressed during differentiation, maturation, and activation of myeloid cells

EMR2/CD312 is a member of the adhesion-GPCR family that contains extracellular EGF-like domains. Previously it has been shown to interact with chondroitin sulphate glycosaminoglycans in an isoform-specific manner. Although EMR2 expression has been found to be restricted to human myeloid cells, its expression profile has not yet been systemically characterized. In this report, we show that EMR2 receptor expression is up-regulated during differentiation and maturation of macrophages, and is conversely down-regulated during dendritic cell maturation. We also demonstrate that EMR2 receptor alternative splicing and glycosylation is regulated during myeloid differentiation. In monocytes and macrophages, EMR2 can be specifically up-regulated by LPS and IL-10 via an IL-10-mediated pathway. In inflamed tissues, EMR2 is detected in subpopulations of myeloid cells including macrophages and neutrophils. The results presented here further support the idea that EMR2 plays a role in the migration and adhesion of myeloid cells during cell differentiation, maturation, and activation.     

Protective effects of melatonin and caffeic acid phenethyl ester against retinal oxidative stress in long-term use of mobile phone: A comparative study

There are numerous reports on the effects of electromagnetic radiation (EMR) in various cellular systems. Melatonin and caffeic acid phenethyl ester (CAPE), a component of honeybee propolis, were recently found to be potent free radical scavengers and antioxidants. Mechanisms of adverse effects of EMR indicate that reactive oxygen species may play a role in the biological effects of this radiation. The present study was carried out to compare the efficacy of the protective effects of melatonin and CAPE against retinal oxidative stress due to long-term exposure to 900 MHz EMR emitting mobile phones. Melatonin and CAPE were administered daily for 60 days to the rats prior to their EMR exposure during our study. Nitric oxide (NO, an oxidant product) levels and malondialdehyde (MDA, an index of lipid peroxidation), were used as markers of retinal oxidative stress in rats following to use of EMR. Superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GSH-Px) activities were studied to evaluate the changes of antioxidant status in retinal tissue. Retinal levels of NO and MDA increased in EMR exposed rats while both melatonin and CAPE caused a significant reduction in the levels of NO and MDA. Likewise, retinal SOD, GSH-Px and CAT activities decreased in EMR exposed animals while melatonin and CAPE caused a significant increase in the activities of these antioxidant enzymes. Treatment of EMR exposed rats with melatonin or CAPE increased the activities of SOD, GSH-Px and CAT to higher levels than those of control rats. In conclusion, melatonin and CAPE reduce retinal oxidative stress after long-term exposure to 900 MHz emitting mobile phone. Nevertheless, there was no statistically significant difference between the efficacies of these two antioxidants against to EMR induced oxidative stress in rat retina. The difference was in only GSH-Px activity in rat retina. Melatonin stimulated the retinal GSH-Px activity more efficiently than CAPE did.