南京鼓楼医院可信电子病案管理系统的设计与实现  

Designing and Implementation of Trusted Electronic Medical Record Management System in Nanjing Drum Tower Hospital

作　　者：刘晓娇 鲍瀛 LIU Xiaojiao;BAO Ying(Computer Center,Nanjing Drum Tower Hospital,Nanjing Jiangsu 210008,China)

机构地区：[1]南京鼓楼医院计算机中心,江苏南京210008

出　　处：《中国医疗设备》2021年第9期109-113,共5页China Medical Devices

基　　金：江苏省重大科技示范项目(BE2018607)。

摘　　要：目的通过梳理医院现有病历归档流程,借助信息化手段,整合现有各类文书,建设一套完整的可信的具有法律保障的电子病案系统。方法引入基于PKI的第三方数字签名技术、组件技术、以及图像处理技术,通过部署数字签名验证服务器、时间戳系统实现各系统的CA认证签名,进一步实现带有时间戳的可信电子病案系统,并向全院推广。结果通过实现全流程电子签名,建设并应用符合国家标准的OFD版式可信电子病案管理系统,推进医院无纸化进程,从时间、空间和经济效益方面为医院节约了大量的人力物力成本,每年节省了300多万的开支,工作效率提高了十几倍,结果显示该系统上线后与上线前存在显著差异,同时实现信息资源优化配置,防止患者信息泄露和篡改,为临床和患者提供更加优质的服务。结论南京鼓楼医院可信电子病案系统的实现,能够有效提升医院无纸化归档的安全性和管理效率,促进医院的信息化建设,进一步保证患者的医疗质量,同时为临床医疗提供了必要的决策支持。Objective To construct a complete and credible electronic medical record system with legal guarantee through sorting out the existing medical record filing process of the hospital and integrating various types of existing documents by means of information technology.Methods Digital authentication based on PKI by third-party institutions was introduced,as well as the component technology and image processing technology.The CA authentication signature of each system was realized through the deployment of digital signature verification server and time stamp system.Furthermore,the trusted electronic medical record system with time stamp was realized and popularized to the whole hospital.Results The trusted electronic medical record system was constructed and applicated in accordance with the national standards of open fixed-layout document format through the realization of the whole process of electronic signature.Finally,the paperless process was promoted,more than 3 million of the expenses of the manpower and material resources,time,space and economic cost were saved every year and the working efficiency was improved by more than 10 times.The allocation of information resources was optimized,the leakage and tampering of patient information was prevented,and better services were provided for clinical and patients.Conclusion The implementation of trusted electronic medical record system in Nanjing Drum Tower hospital can effectively improve the security and management efficiency of paperless archiving,promote the informatization construction of the hospital,further ensure the medical quality of patients,and provide necessary decision-making support for clinical medical treatment.

关 键 词：可信电子病案管理系统 无纸化归档 数字签名 

分 类 号：R197.324[医药卫生—卫生事业管理] TP311.52[医药卫生—公共卫生与预防医学]