高级别医院电子病历系统数据质量评价及对策研究  

Data Quality Evaluation and Countermeasures of Electronic Medical Record System in High-Level Hospital

作　　者：徐帆 舒婷 XU Fan;SHU Ting(National Institution of Hospital Administration,National Health Commission,Beijing,100044,China)

机构地区：[1]国家卫生健康委医院管理研究所,北京100044 [2]国家卫生健康委医院管理研究所医疗信息化研究部,北京100044

出　　处：《中国卫生质量管理》2022年第12期6-9,共4页Chinese Health Quality Management

摘　　要：目的 了解高级别医院电子病历系统数据质量情况,分析问题并提出针对性改进建议,以提高医院数据挖掘和再利用能力。方法 收集2018年-2020年的电子病历评级为高级别(5级及以上)的31家医院数据质量实证材料,梳理并总结医院数据质量状况。结果 31家高级别医院分布在11个省(自治区、直辖市)。电子病历系统数据质量的完整性、一致性、整合性、及时性等方面均存在问题:完整性方面存在数据记录缺失(90.32%)、系统应用不规范(54.84%)、数据字符数不符合要求(12.90%)等问题;一致性方面存在数据字典缺失(83.87%)、数据字典管理不规范(74.19%)等问题;整合性方面存在关联性数据缺失(87.10%)、业务系统孤岛建设(48.39%)等问题;及时性方面存在时间节点缺失(22.58%)、时间逻辑不合理(16.13%)等问题。结论 数据质量意识薄弱以及医院信息系统建设缺乏连通性是主要原因。应提高医院管理者的数据质量意识,定期对数据录入人员进行培训,连通医院各系统以保证关联数据完整性,并建立数据监测系统,以达到数据可用、好用、够用的目的。Objective To investigate the data quality of electronic medical record(EMR) in high-level hospitals, analyze the problems and put forward targeted improvement suggestions, so as to improve the ability of hospital data mining and reuse. Methods The empirical data quality materials of 31 hospitals EMR with high rating(level 5 and above) from 2018 to 2020 were collected, and data quality status were sorted out and summarized. Results There were 31 high-level hospitals in 11 provinces(autonomous regions and municipalities). There were problems in the integrity, consistency, integration and timeliness of the data quality of the EMR. In the integrity, there were problems such as missing data records(90.32%), non-standard system application(54.84%), and non-conforming data word count(12.90%). In terms of consistency, there were problems such as missing data dictionary(83.87%) and non-standard data dictionary management(74.19%). In terms of integration, there were problems such as missing correlation data(87.10%) and island construction of business system(48.39%). In terms of timeliness, there were problems such as missing time nodes(22.58%) and unreasonable time logic(16.13%). Conclusion Weak data quality awareness and lack of connectivity in hospital information system construction were the main reasons. It was necessary to improve the awareness of data quality of hospital managers, train data entry personnel regularly, connect all hospital systems to ensure the integrity of related data, and establish a data monitoring system to achieve the purpose of data availability, ease of use and adequacy.

关 键 词：电子病历系统 应用水平分级评价 数据质量 完整性 一致性 整合性 及时性 

分 类 号：R197.3[医药卫生—卫生事业管理]