基于CDA文档库实现病案利用的多维度精细化管理研究  

Research on Multi-dimensional Fine Management of Medical Record Using Based on CDA Document Libraries

作　　者：吴金波[1] 杨勇[1] 苏韶生[1] 何远源[1] 

机构地区：[1]中山大学附属中山医院信息科,广东省中山市孙文东路2号528403

出　　处：《中国数字医学》2015年第5期107-109,共3页China Digital Medicine

摘　　要：目的:病案的价值在于利用,而利用管理的关键在于做好控制。主要研究终末电子病历的利用管理。方法:在已建立的符合临床文档架构(CDA)标准的电子病历文档库基础上,利用CDA标准的技术特性,来对电子病历文档库中的每个CDA文档进行自我标识,实现以CDA文档为基本单位的细粒度的精细化控制。同时,对涉及利用管理的要素,进行维度分析,建立多维度的权限控制矩阵,实现了管理规则的结构化定制,管理过程的自动化处理。结果:通过这种精细化、多维度、结构化为特征的管理方式,达到了在充分利用病案的同时,实现自动化提供精准服务和保障信息安全可控的目标。Objective：Value of the medical records is to use, and the use of management is the key to good control and management efficiency. The use of management at the end of the study of electronic medical record. Methods： In accordance with the clinical document architecture （CDA） has been established to document library based electronic medical record standards, technical properties using the CDA standard, to carry out the self identification of electronic medical records in document libraries, each CDA document, in order to achieve the CDA document page for fine control basic unit size. At the same time, the relates to the use of the elements of the management, of dimension analysis, control matrix permission to create a multi dimension, implemented structured custom management rules, automatic processing of the management process. Results： By this refinement, multi dimension, structured as a characteristic way of management, in the full use of the medical records at the same time, can achieve purpose of that the medical record information safe and controllable and automation to provide accurate service.

关 键 词：HL7 电子病历文档库 病案利用 精细化管理 权限控制矩阵 

分 类 号：R319[医药卫生—基础医学]