门诊电子病历与医嘱系统的合理搭配与运行  

Reasonable Collocation and Operation of Outpatient Electronic Medical Record and Medical Order System

作　　者：张丽萍[1] 吴文康 Zhang Liping;Wu Wenkang(Information Office,Affiliated Hospital of Jiangnan University,Wuxi Jiangsu 214062,China)

机构地区：[1]江苏省无锡市江南大学附属医院信息处,江苏无锡214062

出　　处：《医疗装备》2021年第19期30-32,共3页Medical Equipment

摘　　要：门诊电子病历与医嘱系统是门诊医师完成门诊诊疗工作的两大支撑软件,一般门诊医嘱系统是在医院信息系统(HIS)中实现的。在门诊电子病历上线之初,医院为了推进其使用,将门诊医嘱系统嵌入门诊电子病历中,通过外键形式来调用。由于两套系统运行环境和要求不同,长此以往会出现搭配与运行不合理的问题。为解决这一问题,特请院内、外专家论证流程、商讨对策,并请门诊电子病历和HIS工程师改进接口、优化程序,经过一系列程序改造与使用培训,目前医院门诊电子病历与医嘱系统运行相对平稳,门诊医师使用满意度得到提升。未来将通过一体化平台将系统之间的散在网状连接转变为各套系统统一与平台做接口,以达到数据标准化与互操作,进而实现以门诊电子病历为基础的互联互通。Electronic medical record and medical order system are two supporting software for clinicians to complete outpatient diagnosis and treatment.Generally,the medical order system is implemented in the hospital information system(HIS).At the beginning of the outpatient electronic medical records were online,in order to promote the utilization of it,the hospital embedded the outpatient medical order system into the outpatient electronic medical records and called them through foreign keys.Due to the different operating environments and requirements of the two systems,unreasonable collocation problems may occur over time.In order to solve this problem,we invited experts inside and outside the hospital to demonstrate the process and discuss countermeasures.Besides,we invited outpatient medical record and HIS manufacturer engineers to modify the interface program and optimize the program.After a series of program transformation and training,the outpatient electronic medical record and outpatient medical order systems(HIS)of the hospital are currently operating relatively smoothly,and clinicians'satisfaction for use has been improved.In the future,we will use an integrated platform to transform the scattered mesh connection between systems into a unified interface between each system and the platform to achieve data standardization and interoperability,and then realize the interconnection based on the outpatient electronic medical records.

关 键 词：门诊医师站 电子病历 医嘱系统 医院信息系统 一体化平台 互联互通 

分 类 号：R197.324[医药卫生—卫生事业管理]