电子病历数据质量研究的国内外差异  

Study on the Difference of Data Quality Researches on Electronic Medical Record at Home and Abroad

作　　者：任牡丹 杨柳 殷杰 吴义熔[4] Ren Mudan(School of Government,Beijing Normal University,Beijing,P.R.China.)

机构地区：[1]北京师范大学政府管理学院,北京100875 [2]北京师范大学心理学部 [3]南京医科大学第四附属医院(浦口医院) [4]北京师范大学人文和社会科学高等研究院

出　　处：《中国卫生事业管理》2023年第4期268-274,共7页Chinese Health Service Management

基　　金：国家社会科学基金项目“基于数据语义化的电子病历数据质量研究”(20BTQ066)。

摘　　要：目的:医疗机构在日积月累中储存了大量数据,这些数据可以用于临床医学、科研工作、医院管理等,良好的数据质量是保证这些数据发挥作用的重要基石。方法:本文以国外Pubmed收录的1016篇数据文献和国内CNKI期刊数据库收录的97篇研究论文为样本,以内容分析法为主,文献计量分析为辅,对比分析国内外电子病历数据质量研究的热点主题及主要内容。结果:从被检索文献来源来看,国外对电子病历数据质量的研究探索较早,持续时间较长,如今已经步入持续发展阶段,而国内还处于不断探索和持续推进阶段,未来还有较大的发展和改进空间。从研究主题上来看,国外虽然与国内研究主题有所重叠,但探索方向更加广泛,研究领域也更加深层次一些。从研究内容上来看,如何提升数据质量是国内外学者关注的共同话题,本文具体是从数据质量存在问题和提升方法两方面所存在的差异性展开具体描述。结论:与国外相比,我国电子病历数据质量研究在广度和深度上还存在很多不足,建议通过加快构建电子病历数据质量研究的理论体系框架,加强多领域合作和有效嵌合国家治理理念等方面拓宽研究领域和范围,推动我国在电子病历数据质量方向的长久发展。Objective To study the quality of data from medical institutions for clinical medicine,scientific research and hospital management.Methods 1016 research literature from PubMed and 97 research papers from domestic CNKI journal database were collected,and studied with content analysis method and bibliometric analysis method.Results In terms of the source of literature,researches on the quality of electronic medical record(EMR)were earlier and kept for longer time at abroad,which has entered a stage of sustainable development.While researches on EMR data quality in China is still in the stage of continuous exploration and promotion,which has great room for development and improvement in the future.In terms of research themes,although the research themes of foreign and domestic papers were partially overlapped,research fields and directions of foreign papers were wider than those in domestic papers.From the perspective of research content,how to improve the data quality is a common topic to scholars at home and abroad.Conclusion Compared with foreign countries,there are still many deficiencies in the breadth and depth of researches on the quality of electronic medical record data in China.It is suggested to broaden the research field and scope by accelerating the construction of theoretical framework for the research on the quality of electronic medical record data,strengthening cooperation in multiple fields,and effectively embedding the concept of national governance,so as to promote the long-term development of the quality of electronic medical record data in China.

关 键 词：电子病历 数据质量 医疗数据 质量提升 

分 类 号：R197[医药卫生—卫生事业管理]