基于临床数据中心的单病种质量管理系统设计与实现  

Design and Implementation of the Single-disease Quality Management Information System Based on CDR

作　　者：黄虹[1] 邵建华[1] 邹玉蓉[2] 

机构地区：[1]复旦大学附属华山医院,上海市乌鲁木齐中路12号200040 [2]复旦大学附属华山医院信息中心,上海市乌鲁木齐中路12号200040

出　　处：《中国数字医学》2016年第2期31-33,42,共4页China Digital Medicine

基　　金：国家高技术研究发展计划(863计划)项目-数字化医疗医院流程研究及应用示范(编号:2012AA02A613)~~

摘　　要：目的:在医院临床数据中心(CDR)平台上,开发建设单病种质量管理系统,建立并完善单病种质量评价标准体系。通过在诊疗流程中嵌入节点监测和管控,实现对病种质量指标的监测、统计和分析工具,提供医务部门进行管理干预的抓手,以规范临床诊疗行为,加强医疗质量管理,提高医疗服务水平。方法:在CDR平台汇集全院临床数据,构建主题数据集市(Data Mart),运用数据挖掘技术建设单病种质量管理系统,实现单病种质量管理的一整套指标体系,对单病种诊疗过程关键环节进行质量监测与控制。结果:通过开发建设,梳理并完善了诊断标准、过程监测要求等业务规则,实现了单病种质量管理KPI体系;同时通过对电子病历和电子医嘱(CPOE)进行改造与完善,健全了诊疗过程的全流程节点监控机制。结论:通过推广使用该系统,可以帮助我院提高单病种管理的准确性、及时性和可比性,提高数据统计、分析的效率,为医院落实单病种质量管理要求提供现实的抓手。Objective： To develop and construct the single disease quality management system,and establish and improve the quality evaluation standard system of single disease on the clinical data center（CDR） platform of our hospital. Through the monitoring and control of embedded nodes in the diagnosis and treatment process,the monitoring,statistics and analysis of disease quality indicators is realized,and a tool for management and intervention is provided to the medical departments,so as to standardize the clinical diagnosis and treatment behaviors,strengthen the medical quality management and improve the medical service level. Methods： The CDR platform gathers clinical data of the whole hospital,the subject Data Mart is built,with the data mining technology the single disease quality management system is constructed,a set of index system for the single disease quality management is realized,and quality monitoring and control of key links of diagnosis and treatment process of single disease is completed. Results： Through the development and construction,the diagnostic criteria,process monitoring requirements and other business rules are summarized and improved,and the quality management KPI system of single disease is realized; at the same time through reforming and improvement of electronic medical records and Computerized Physician Order Entry（CPOE）,the whole-process node monitoring mechanism of the diagnosis and treatment process is improved. Conclusion： The promotion and use of the system can help our hospital to improve the accuracy,timeliness and comparability of single disease management,improve the efficiency of data statistics and analysis,and provide a realistic tool for the hospital＇ s meeting of the requirements of single disease quality management.

关 键 词：单病种质量管理 临床数据中心 临床过程监测 

分 类 号：R197.3[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]