区域医疗环境下电子病案系统的应用与管理  

The Application and Management of Electronic Medical Records System in Regional Medical Treatment Environment

作　　者：陈丽[1] Chen Li(Department of Medical Records, Beijing Tiantan Hospital Affiliated to Capital Medical ,Universitv, Beiiinz 100050. China)

机构地区：[1]首都医科大学附属北京天坛医院病案科

出　　处：《中国病案》2017年第7期46-49,共4页Chinese Medical Record

摘　　要：为了适应医疗行业的发展进程,电子病案成为了医院病案管理的新模式,并发挥重要作用。可信电子病案的生成是在患者出院后,通过电子病历归档系统把患者住院期间的各类数据转化成PDF类型的开放格式,其中包含了数字化认证的医嘱与电子病历,还包含了化验、检查数据。而且还包括数字证书、身份签名认证、电子签名等数据。电子病案安全的保证通过三方认证、电子签名、三级审签、安全存储实现。区域内不同医院及医疗机构间的数据共享及交换能够优化区域内的卫生资源、降低医疗费用,提高医疗服务的质量和效率,改善和提高区域内的卫生综合服务能力。完善以医院财务和医疗业务为中心转化到以病人为中心医院信息化建设,电子病历的建立和完善将成为核心内容。而区域卫生信息化将在区域内以电子健康记录为核心,与医院电子病历有效衔接,消除各家医院独立发展造成的信息孤岛,通过双向转诊和远程回证进一步得以实现。保证区域性卫生信息资源的统一性、规范性、完整性和开放性,实现院际之间医疗资源共享和协作发展,有助于全面提升医疗服务质量,推进医疗服务的可持续性发展。In order to adapt to the development of medical industry, the electronic disease case has become the new model of hospital disease management and plays an important role. Reliable electronic medical record is generated after discharge from hospital, through the electronic medical record filing system converts the hospitalization of patients with all kinds of data to PDF type open format, which contains the digital certification of the doctor＇s advice and electronic medical records, also contains a test, check the data. Digital certificates, identity signatures, and electronic signatures are also needed. The guarantee of electronic medical case safety is achieved through tripartite authentication, electronic signature, tertiary examination and safe storage. Area between different hospitals and medical institutions to optimize data sharing and exchange area of health resources, reduce the medical cost, improve the quality and efficiency of medical service, improve＇ and enhance regional health comprehensive service ability, The core content will be the ＂establishment and perfection of electronic medical recordsi which is transformed into the information construction of hospital finance and medical service. And regional health informatization in the area with electronic health records as the core, the effective connection with the hospital electronic medical records, eliminate hospitals independent development of the information island, through the certificate of two-way referral and remote further implemented. Ensure unity of the regional health information resourcesl, the standardization, integrity and openness, medical resource sharing and collaboration between hospital international development, help to improve medical service quality, promote the sustainable development of medical service

关 键 词：区域医疗 电子病案 应用 管理 

分 类 号：R197.323[医药卫生—卫生事业管理]